The Medical Termination of Pregnancy Act of 1971 greatly liberalised the indications for which abortion is legal in India. The Government intended for this Act to reduce the incidence of illegal abortion and consequent maternal morbidity and mortality. However, 30 years after the groundbreaking legislation, the majority of women seeking abortion still turn to uncertified providers for abortion services because of the barriers to legal abortion. While some uncertified providers offer safe services, many provide unsafe abortions that result in complications or death. Women with access to fewer resources, for example low-income rural women and adolescents, are among those most likely to turn to unsafe abortion and have complications. Studies suggest that the choice of specific provider is most often not made by the woman inducing abortion but with or by her husband or other family members.
While the incidence of abortion in India is unknown, the most widely cited figure suggests that around 6.7 million abortions take place annually. According to government data, only about one million of these are performed legally. The remaining abortions are performed by medical and non-medical practitioners. Levels of unsafe abortion are very high in India, especially given that abortion is legal for a broad range of indications, and available in the public and private health sector.
In the current situation abortion services are not adequately decentralized, and regulatory reform will have to take place before decentralization of legal services will happen in a meaningful way. To reduce morbidity and mortality from unsafe abortion in this context, several broad activities require strengthening: decreasing unwanted pregnancies; increasing access to safe abortion services; and increasing the quality of abortion care, including postabortion care.
Results of the studies reviewed suggest that reducing recourse to unsafe abortion will be a
Abortion Practice in India: A Review of Literature
Heidi Bart Johnston
complex multi-step process that includes increasing womens access through improve- ments in service delivery and addresses the more complicated issues of rights and gender power inequities. Strategies to make safe and legal abortion services more attractive to women and decision makers include: increasing geographic accessibility; increasing affordability; providing high quality abortion care and prioritising confidentiality of services. Addressing the system of barriers limiting womens access to safe abortion services may require review and revision of the MTP Act, 1971 and associated rules and regulations.
This review suggests a need for expanded community-based education to address specific issues of womens reproductive health and the broader issues of womens right to high quality health care services. Household decision- makers, men and women, would benefit from awareness raising about the dangers of unsafe abortion and the availability of safe abortion services. Women with reduced access to reproductive health resources, such as adolescents and rural poor, should be a priority focus in com-munity-based education.
This review of the current literature of abortion in India suggests that abortion and associated morbidity and mortality from unsafe abortion are common and need to be a top priority safe motherhood issue in India. Areas for exploration to improve abortion care include, but are not limited to: motivating qualified practitioners to attend MTP training courses; reviewing MTP Act and associated rules and regulations to determine how the law can be revised to decentralize abortion services and otherwise better meet the needs of women; upgrading facilities that currently offer MTP services; orienting MTP services to meet the needs of women most at risk of accessing unsafe abortion; increasing awareness among women and men of reproductive age of the availability of safe abortion services and the dangers of unsafe abortion; involving communities and providers at all levels to
improve reproductive health care; and improving adolescent reproductive health services in general. Innovative interventions need to be developed, implemented, monitored and scaled up as appropriate.
Clearly a great deal is known about provision of and access to safe and unsafe abortion services in India and the need to improve safe abortion and contraceptive choices to more
adequately meet the needs of women experiencing unwanted pregnan-cies. Still, a great deal more needs to be known before programs are implemented to ensure low- resource Indian women can readily access safe abortion services. The cost in terms of womens health and lives emphasizes the need to efficiently and effectively pursue efforts to make abortion safer and more accessible for Indian women.