Investigating Provider-level Factors Facilitating and Impeding Women's Access to Medical Abortion in India
A Council study in India found that although medical abortion is provided by both certified and uncertified providers, awareness of the method is limited, national guidelines are not necessarily followed, and attitudes about expanding the provider base to include midlevel providers are generally unfavorable.
This study, which took place in Bihar and Maharashtra, focused on understanding the perspectives and experiences of certified and uncertified abortion providers. Researchers surveyed 270 certified providers (240 obstetrician/gynecologists and 30 general practitioners), and 930 uncertified providers (210 general practitioners, 240 AYUSH [physicians trained in Indian systems of medicine, including homeopathy], 240 nurses/auxiliary nurse midwives, 182 rural medical practitioners, and 58 traditional birth attendants). In-depth interviews were conducted with 17 certified and 17 uncertified providers.
Almost all certified physicians were providing abortion services at the time of the interview (97%), but only 67 percent provided medical abortion (MA), along with 11 percent of midlevel providers, 8 percent of informal providers, and 5 percent of uncertified physicians. Almost all of these providers reported routinely counseling clients about the procedure and about contraception. Among those who provided MA services, awareness was incomplete; while 92 percent of certified providers were aware of the correct timing of misoprostol administration, just 64 percent and 41 percent were aware of the correct gestational age limit and dosage of mifepristone and misoprostol for MA, respectively. Uncertified providers were even more poorly informed; only 78 percent, 58 percent, and 33 percent were aware of timing, gestational age limit, and dosage, respectively.
Attitudes about the appropriateness of MA for different groups of women varied. Certified providers were much more likely to consider MA appropriate for the well-educated than others (74% vs. 39%); uncertified providers were less likely to display such attitudes (70% vs. 65%). Attitudes about the safety and efficacy of MA provided by midlevel providers and chemists were uniformly negative. Medication purchased directly from a chemist was considered safe and effective by just 1–6 percent of providers, irrespective of category. Homeopaths were considered safe and effective by only 21 percent and 35 percent of certified and uncertified providers, respectively. Nurses/auxiliary nurse midwives were positively perceived by 47–58 percent of physicians, 64 percent of informal providers, and 73 percent of midlevel providers.
Project findings have been presented in meetings and consultations on midlevel provision of abortion attended by representatives from the Ministry of Health and Family Welfare, Government of India. Findings highlighting that (1) uncertified providers are indeed providing MA, including in underserved rural areas, and that (2) providers—both certified and uncertified—are poorly informed about MA and that many certified providers would withhold MA from poor and uneducated women, were emphasized in these meetings to justify the need for training providers (including midlevel providers) in medical abortion. Findings have also been used in considering the expansion of the MA provider base to include midlevel providers, especially in underserved rural areas.
An article on certified providers' knowledge, attitudes, and practices has been prepared and accepted for publication in International Journal of Gynecology and Obstetrics. This will also be used by the World Health Organization's Reproductive Health and Research Department to disseminate evidence on medical abortion in developing countries.
No publications are listed
Location: India (four districts each in Bihar and Maharashtra)
Safe abortion and postabortion care
Duration: 11/2009 - 12/2011
Population Council researchers:
World Health Organization