The Medical Termination of Pregnancy Act (MTP) was passed in 1971 in India and a major reason to bring this Act, was to reduce the mortality caused due to unsafe abortion practices in the country. Even after three decades of its passage more than 90% of people are unaware of the Act and its provisions. This has resulted in unsafe abortion practices remaining one amongst the five biggest causes of maternal mortality accounting for 8.5% maternal deaths in our country (RGI Governement of India 2013).
The status of antenatal care (ANC) in Uttar Pradesh (UP) is poor with only 5.9% women receiving complete ANC. Further, there is a high prevalence of anemia with 52% of all women being anemic (National Family Health Survey 4, 2015-16). The MMR which is 258 (Annual Health Survey, 2012-13) is higher than the national average. In UP, there are around 50 lakh pregnancies annually of which 12% (6 lakh) end in an abortion or miscarriage. Of these six lakh abortions 45% are conducted at home either by the woman herself, or with the help of her family member or someone from the community. Another 46% of the abortions are conducted in private clinics. Further, in case of complications related to abortion 76% women sought care in private facilities as the government hospitals are not equipped to handle the cases of complications. This is despite the fact that the government runs a comprehensive program to promote safe abortion. (National Family Health Survey 4, 2015-16)
Background to the HealthWatch Forum Study
In order to explore the status of abortion services at the community level a study was carried out by Health Watch Forum (HWF), Uttar Pradesh from December 2017 to February 2018 in 12 districts of Uttar Pradesh UP. The methodology included Key Informant interviews with District Health Officers, Medical Superintends of Community Health Centres, informal healthcare providers and medical store representatives. Focused Group Discussions with women were also carried out.
- Availability of abortion services/ Status of Abortion Services under Medical Termination of Pregnancy (MTP) Act
The study revealed that none of the women from the 12 districts had information about the provisions under the MTP Act. Services for Medical termination of pregnancy (MTP) were available only in 2 Community Health Centres (CHCs) namely Faizabad and Barabanki out of the 12 CHCs covered under the study. None of the other government hospitals had any information displayed inside their premises providing information about MTP services nor was the ASHA given any orientation on the subject due to which she was unable to provide information at the community level.
Medical Termination of Pregnancy can be legally offered by private facilities; in 2010 the Central government had issued guidelines under Comprehensive Abortion Care: Training and Service Guidelines where 943 private clinics were accredited for MTP services in addition to the government hospitals in Uttar Prdaesh. However, if we look at the website (http://cacuttarpradesh.in) there are only 212 centres whose details are mentioned.
- Access to abortion services
Another finding of the study was that in the absence of knowledge and lack of abortion services close to the village, women were left with no choice but to rely on the traditional birth attendants or other women from the village for guidance. The most common method to get an abortion at home was the use of local herbs which causes the foetus to abort itself. Women also sought the services of informal providers who conducted abortions using some tools. Women also relied on medicines that were easily available at pharmacies for around five hundred rupees which they self administered without a doctor’s prescription or guidance.
“Consumption of a ground carrot or ridged gourd seeds along with water is a common way to perform abortion at home. Since there are no services for safe abortion near the village, women either visit the quack who prescribes the medicine and does his own treatment for which the charge is anywhere upto 3000 rupees or they take the pill from the pharmacy directly.” Gita (village woman Azamgarh District)
Untrained providers and homeopathy doctors often prescribed medicines to women without conducting any physical examination or asking for details to ascertain how advanced the pregnancy was, even in cases of a prior failed attempt of abortion at home. In cases of complications, women are refered to private nursing homes from by these untrained providers and homeopathy doctors in lieu of a commission for every referral. The women from Azamgarh Distirct shared that even in the government hospital; the doctor charged an informal fee of upto 7000 rupees for handling the cases where complications arose due to a failed abortion attempt.
Another finding was that there were no records maintained for the women who were prescribed pills or homeopathy medicine by the untrained providers or the pharmacist. Neither the pharmacist nor the government facility maintained any list of these women.
Responses from the Health Department Officials
Interviews with the officials from the health department revealed that there is a district level committee for the monitoring of the centres offering MTP services which were not very active. They also cited the dearth of trained female doctors and other staff in the health centres due to which the abortion services suffered. This is corroborated by DLHS-4 data which shows that in Uttar Pradesh only 14% of the CHCs have a gynecologist appointed and only 11% have an anesthesist.
The district officials also said that inspite of the demand for MTP being very high across the districts (77 in 6 months in Barabanki district hospital, 684 in Jalon district hospital) there is no effort being taken by the government to spread awareness or to improve the services which is evident in the fact that there is no dedicated budget for the program. Further, in Gorakhpur, the average numbers of cases are as high as 1300 in a year but there is no proper record of the number of MTP centres available in the district.
The findings from the study point towards the apathetic status of MTP services at the community level which jeopardizes a woman’s health as she is left with no choice than to depend upon unqualified healthcare providers for care. HealthWatch Forum is dedicated and striving to improving women’s reproductive health and services at all levels and drawing from the study has the following recommendations to the Health Department to ensure availability and accessibility of quality MTP services for the women-
- To create awareness about the MTP services act by displaying information about the nearest accredited centre at all subcentres, primary health centres and community health centers.
- To make the Safe MTP services available at the PHC and CHC Level so that the women have ease in access.
- To constitute a strong public health policy and system so that the MTP services can be improved.
- To make stricter guidelines for centres to get accredition under MTP act.
- To appoint required number of trained female gynecologists at the health centres.
- To train the government as well as accredited private heath practioners on new technology so that they are able to provide quality services with a special focus on managing complications during or post abortion.
- To train and equip the ASHA, AWW and ANM with information to address the various myths associated with abortion as a method and its services.
- To ensure availability of family planning services of quality and to promote use of safe contraceptive methods.
 Avalible at: https://srhr.org/abortion-policies/documents/countries/04-India-Comprehensive-Abortion-Care-Training-and-Service-Delivery-Guidelines-Ministry-of-Health-2010.pdf