From decoctions to instruments
EVEN though the Medical Termination of Pregnancy (MTP) Act 1971 bars unqualified and untrained persons from conducting abortions, informal providers (IP) of abortion still thrive in different urban, rural and tribal areas of India. The MTP Act specifies that a pregnancy may be terminated within the first 12 weeks of gestation on the opinion of one registered medical practitioner and that the concurrent opinion of two registered medical practitioners is required for aborting a pregnancy between 12-20 weeks. An abortion can be performed only by a registered medical practitioner in a hospital established or maintained by the government or in a facility approved by the government, based on certain quality specifications regarding infrastructure and equipment.
The act defines a registered medical practitioner as one who has a recognized medical qualification as defined in the Indian Medical Council Act, which essentially deals with the registration of allopathic doctors whose name is entered in the state medical register. It further states that to conduct abortions the doctor with the above mentioned qualification and registration should have experience or training in gynaecology and obstetrics as prescribed in the rules under this act, which were framed by the Ministry of Health and Family Planning in October 1975.
According to these rules, a doctor was entitled to conduct abortions if he had a post graduate degree or diploma in obstetrics and gynaecology, or had worked six months as house surgeon in obstetrics and gynaecology, or had assisted a registered medical practitioner, as defined above, in conducting at least 25 abortions, or was registered in the state medical registry and had three years of experience in obstetrics and gynaecology prior to the commencement of the act.
However, despite such elaborate specifications of the qualifications, experience and training on the eligibility of doctors to conduct abortions, a multi-state study of informal providers of abortion coordinated by Health Watch and IPAS shows that unregistered providers operate even in the national capital. Other studies conducted in the rural areas of Kanpur district in Uttar Pradesh, Jind district of Haryana, and rural and urban areas of Sidhi and Ujjain districts in Madhya Pradesh reveal that such practitioners are prevalent in varying degrees in different parts of India.
Not surprisingly, districts with a substantial tribal population such as Nasik in Maharashtra and Chamarajnagar in Karnataka where the study was conducted have several such practitioners. The present set of studies of IPs, which are summarized here, are exploratory in nature and based on qualitative methods such as in-depth interviews (IDI) with the IPs and women who have undergone abortions by IPs and focus group discussions (FGD) with women.
These studies address issues such as: why women approach IPs for abortion, who the IPs are in terms of gender, socio-economic status and education, how they learnt to carry out abortions, how they attract clients, their success in conducting abortions and handling complicated cases their relationship with the formal system and dealing with the law?
Depending on the study area, the studies are grouped together under urban and rural areas, a combination of both, and the tribal area. Brief summaries of each are presented below with a conclusion.
Urban study – Delhi: The Tigri resettlement colony in south Delhi has a population of 15000, comprising mainly of Hindus with a few Muslims, Sikhs and Christians. The majority are skilled or unskilled daily wage workers, a few government employees and some petty shop owners. The household income in this colony is estimated to be between Rs 2000-8000. There are two neighbourhood hospitals within a distance of two to three kms. Other providers of health care are non MBBS doctors and quacks.
The informal providers of abortion in this area include dais, nurses, unqualified doctors, chemists and women who have worked with doctors or with dais and learnt doing abortion. Informal providers are seen as individuals practising abortion, with some minimal training or experience in the ‘art’ of abortion. They pick up this art from a dai or doctor by working with them and then set up their own ‘shop’. The procedures used for abortion include giving orally consumable herbs, home made preparations (kadhas) or capsules, to inserting medicines and instruments in the vagina.
IPs enjoy a positive and congenial relationship with clients, for they are viewed as low cost providers of an important service. As such, the clients themselves are their protectors and allies. They use a range of strategies to remain anonymous and elude discovery. Their practice is publicised only through word of mouth and within a limited network. Typically, they practice from a residential house without setting up ‘shop’. It is, therefore, difficult to distinguish trained from untrained or qualified from unqualified doctors. IPs sometimes deceive their clients by practising in posh outfits to give the impression of being qualified doctors.
IPs manage complications and mishaps that may arise through their connections with formal providers and the police. Formal providers (FP) may pay a commission to the IPs for referrals. The police would be managed through bribery. FPs view the services of IPs as illegal, but feel that they enjoy the confidence of the community.
Married women, unmarried girls and other single women often approach the informal providers. Women in this area usually wait for a couple of days after the expected date of menstruation for it to get regularized. Then they would take herbal preparations to start their periods. Only a few women would not take these herbals and seek a pregnancy test from the doctor. If the menstruation does not get regularized, they would share the problem with husbands or senior family members who would then decide on the need for abortion.
Rural studies – Kanpur district, Uttar Pradesh: The study area of one of the two rural studies on abortion is located 35 km from Kanpur city. Its population is mostly multi-caste Hindu, a third being from the lower castes. There are two PHCs in the area, both ill-equipped and not staffed to handle emergencies or provide proper care. Therefore, private practitioners proliferate in the area. The nearest referral institutions are in Kanpur city, which includes a medical college.
IPs conducted abortions ranging from the third to as late as the seventh month of pregnancy. In the case of unmarried girls it ranged from the fourth month to very advanced stages of pregnancy! In the study area, around 15 to 20 women undergo unsafe abortions every year. Out of them two to four cases develop complications, the more severe ones among them even resulting in death.
On an average the fee charged by IPs for conducting abortion on married women varied between Rs 100 to 300. However, the fee for unmarried women was as high as Rs 2000-5000, exploiting their need to protect honour and keep secrecy. For women the typical sequence of seeking an abortion begins with trying out home remedies. This consists of eating hot things like jaggery, castor seeds and eating/drinking sour items like vinegar. Subsequently, midwives are approached for medical advice, which is followed by seeking help from the IP.
Married and unmarried girls, widows and women whose husbands are away seek the help of IPs for conducting abortions. The main reasons for not going to professionally qualified doctors is the expense involved and often because they are unapproachable. At the same time women, including adolescent unmarried girls, suffer physically and may end up paying more money due to the complications arising from unsafe abortions. Therefore, the study recommends the setting up of an adequate number of accessible facilities managed by qualified professionals.
Jind district, Haryana: One PHC village from Safidon block and another from Uchana block of Jind district form the study area for the second rural study on IPs. Safidon is 10 kms from the first PHC village mentioned, and Jind is 20 kms from the second village. Doctors are not available in the PHCs and people generally have no faith in the quality of treatment. They depend on the government referral centres in the towns of Safidon or Jind, or on private providers.
Out of the seven IPs interviewed, six are males and one female. Three have studied upto 12thstandard, two are undergraduates, one has studied upto 10th and one upto fifth standard. All of them learnt about doing abortions from FPs in the nearby towns. Their average experience is 4.3 years. During fieldwork it was felt that ANMs in these villages were doing abortions, but they were reluctant to talk to the researchers who were perceived as outsiders. Their attitude was, ‘matters of the village should remain in the village.’
The normal sequence in the case of a delay in the onset of periods starts with home remedies or ‘over the counter’ drugs from chemists, then seeking help from dais, health workers, IPs and approaching FPs should the need arise. Some women also directly went to the FPs. However, the study reports that women, by and large, are increasingly approaching FPs in the nearest towns who are expensive but effective.
At an early stage of regulating menstruation, dais use kadhas of various types. Supposedly hot items like carrot seeds, radish seeds, cotton seeds, garam masala, lentils and old jaggery, are used in different combinations for making these kadhas. Milk, dry fruits and tea are the other ingredients. According to women in the FGDs, dais only recommend these items, which they perceive to be within their domain.
In the case of miscarriages, women either go directly to FPs or try out kadhas and if the pain and bleeding continues, approach the FPs in the town for safai (abortion). Some women, however, depend on the village doctors.
IPs do not openly admit to doing abortions. They refer to the related services as regulation of delayed menstruation. Four providers claimed that they treat delayed periods up to three months. Two said that they treat it only up to 20 days. Treatment consisted of medicines or injections to abort. None of them mention the use of instruments. This was corroborated by the women in FGDs. Most providers used Erga Cap with combination of other medicines such as Reguline, Methergine or Lariago. If these did not work, Prostodine injection was given.
These IPs are confident and claim to follow the same line of treatment as the FPs. They profess not having faced any complications. At the same time they did not trust the efficacy of their medicines and injections for pregnancies over two to three months. Such cases were referred to FPs in the towns of Safidon or Jind.
For abortions, IPs charge Rs 80-100 for medicines and between Rs 150-200 for injections. Women who are better off go directly to FPs for abortion. Only those who can’t afford the formals first go to IPs. The community is aware of the limitation of informal providers. On their part, IPs refer cases they cannot treat to the FPs in the towns of Safidon and Jind.
Rural and Urban – Sidhi and Ujjain districts, Madhya Pradesh: The relatively urbanized block of Waidhan in Sidhi district and the predominantly rural block of Tarana in Ujjain district form the area for this study which was coordinated by IPAS. Singrauli coal fields are located in Waidhan block, and coal mining is a major economic activity, while Tarana is mainly agricultural. Regular employees of the Northern Coal Limited (NCL) and the National Thermal Power Corporation (NTPC) in Singrauli can approach the Nehru Satabdi Hospital of NCL and the NTPC hospital respectively for abortions. But the contract employees, who work under various thekedars do not have this facility and are, therefore, forced to depend on IPs. Tarana resembles other rural areas in other states studied in this connection. Twenty IPs were interviewed, and 19 FGDs with women were conducted.
There is a clear preponderance of males among the IPs, with 18 males (90%) and only two females. The mean age of the 20 IPs interviewed from Waidhan block in Sidhi district and Tarana block in Ujjain is around 37 years with a range of 26-58 years. Ten IPs have middle or high school education while nine are graduates and one is a post graduate. Among the IPs there are 14 (70%) RMPs/village practitioners, three (15%) who described themselves as herbalists, only one nurse and one ANM. They have on average 10.5 years experience in conducting abortions, the skills acquired through practice with other qualified doctors and by repeated performance.
On further probing, all IPs reluctantly admitted to treating delayed periods. Sixteen out of twenty (80%) treat for leucorrhoea, bleeding and anaemia as well. All the IPs manage common illnesses like fever, cold, cough, headache, vomiting and diarrhoea and conduct deliveries. IPs consider treating delayed periods as an aid to women to get back their periods and never use the word abortion for treating delayed periods.
The medicines used by IPs to treat delayed periods/abortion vary to some extent with each provider. Out of 20 informal providers, 16 (80%) use allopathic medicines like EP Fort (tab), MC Cap (tab), Cyclofort (tab), MC Run (tab), Gynamin Fort (tab), Mensulin Fort (tab) and injections like Prostodine and Uniprogestron. MC Cap, Cyclofort, MC Run, Gynamin Fort, Mensulin Fort are not mentioned in Drug Today or Current Index of Medical Specialities and could be preparations of doubtful quality.
Nine IPs say that they use ayurvedic medicines like Ashokarista, some churans and home-made decoction. The ingredients of these medicines are not revealed. FGDs with women, however, indicate that these herbal medicines are rarely used.
Out of the 20 IPs interviewed, two female and six male (40%) IPs, admit that they use instruments to treat delayed period or abortion. It is after much probing that these providers admitted using instruments like scissors, syringe, sponge holders, curette, ovum forceps, MR syringe, speculums and D&C instruments.
Seven IPs (35%) provide abortion up to eight weeks while 12 (60%) take cases up to 12 weeks. One female provider, a nurse, conducts abortions up to 16 weeks for a fee of Rs 1000-1500. IPs do an average of 5.7 abortions every month. For abortions up to 12 weeks, IPs charge an average minimum amount of Rs 147.5 with a range of Rs 50-500 and an average maximum amount of Rs 288.75 with a range of Rs 75-1000. All informal providers claim that they maintain privacy of clients, which is crucial for sustaining their practice.
Two FGDs conducted near Waidhan town reveal that for regularizing delayed periods and for abortions women preferred the CHC in Waidhan. The other 17 groups in Widhan and Tarana blocks mostly relied on IPs. The reasons for using IPs were easy availability, familiarity, lack of nearby government facilities, non-availability of doctors in government facilities, apathetic attitude of government health personnel and the lower cost of IPs compared to formal providers. At the same time the participants in the FGDs state that informal providers are successful only in some cases, the success depending on the nature of the cases.
Tribal studies – Nasik district, Maharashtra: The tribal area of Nasik district is inhabited by Konkana, Koli, Warli and Thakar tribes. One of the studies on IPs among the tribal people has this as its study area. Though the PHC and CHC in the area do function, few abortions are done there.
Every village does not have an IP, but people seek them wherever available. Education of the IPs vary from illiterate to seventh standard. Their experience ranges from 8-29 years. All but one of the IPs use herbal medicines. The one who doesn’t use herbs, does stick insertion. The usual clients are unmarried women and women who conceive outside wedlock. It appears that failure of contraceptives was not a reason for abortion among tribals. The practise of female foeticide also does not to exist.
IPs do abortion of early, one to two month old, pregnancies, the fees varying between Rs 200-500. But ‘the greater the need for secrecy and the longer the pregnancy, the higher the fee.’ They practice at their homes and rarely at the clients’ houses. Their methods reportedly work, though one case of death was recently reported. Informal abortions are on the decline, according to this study.
Women in the FGDs enumerated the weakness of public MTP facilities. IPs are more community friendly than the doctors and other personnel at MTP centres. Herbal methods are more acceptable than the traumatic one of curettage. This study observes that doctors at most public MTP facilities also charge the same amount as IPs, but people find IPs easier to deal with. They can pay in instalments, or pay after the abortion as well.
Fear of getting a bad name by being seen and recognized by others at the PHC is a major reason driving women to the IPs. At the IP’s home, she is the only patient while at the PHC or CHC 40 to 50 people would be thronging the OPDs. Women are also scared about news of their having undergone abortion spreading through the lower level staff of the PHC/CHC who know them and the villagers.
Chamarajnagar district, Karnataka: Tribal areas under the Gumballi PHC limits and tribal population in Kollegal and Chamarajnagar taluk of Chamarajnagar district in Karnataka forms the area of the second study on IPs among tribal people. A preliminary abortion survey conducted in the area revealed that 82% of the women who underwent abortions were married and only 18% unmarried. The survey also showed that 22% among the tribal population and 14% among non-tribal population had undergone abortions conducted by IPs.
Many married and unmarried women, divorcees and widows seek abortions. The informal providers in the tribal area are normally over 35 years of age, illiterate and engage in wage labour. They also treat common ailments. IPs are traditionally trained women from the community, ANMs/retired ANMs, trained dais, LHVs/ retired LHVs, ‘village doctors’ untrained in MTP, and ayurvedic doctors. They conduct abortion up to 12-16 weeks and refer to the hospital if a pregnancy crosses 16 weeks. They charge Rs 100-200 for abortions and occasionally receive payment in kind, such as rice/wheat.
IPs are preferred over the FPs for reasons of cost, confidentiality, access and familiarity. A majority use a green coloured medicine (kashayas). IPs have few complications as they often terminate pregnancies in the first trimester, usually with herbal medicines and rely less on invasive procedures, which if used without training, can lead to complications. Complicated cases are referred to the health centres/hospitals.
In Chamarajnagar, the IPs have of late begun to take women even in the first trimester to hospitals/clinics and receive a remuneration from the FPs. Further, that women in the study area now prefer the services of FPs due to increased awareness. Despite the declining trend, a considerable part of abortion services continue to be provided by IPs.
Informal Providers of abortion function across the urban, rural and tribal areas of India. The provisions of the MTP Act have not curtailed their work for various reasons. Considerations of cost, confidentiality, familiarity, easy availability, easy systems of payment, non-availability of abortion services in government health facilities in rural areas, absence of government health personnel in institutions and their apathetic nature when available, lack of privacy in government facilities and the traumatic nature of some formal methods of abortion are factors which push women to IPs.
It appears that some of the traditional medicines used by IPs from the tribal communities are effective in first trimester abortions. These need to be scientifically studied and taken up for wider dissemination. Informal providers of abortion cannot be wished away, given the fact that abortion facilities are not offered by the PHCs in different parts of India and the exorbitant charges of formal providers in the private health sector.
It is time that PHCs were activated/facilitated to provide abortion services. It is also necessary to integrate the IPs within the formal systems in both government and private health sectors. Through training, they must be enabled to handle non-complicated abortions in the first trimester without using invasive procedures, restricting themselves to medicines which do not produce side-effects.
Medical Termination of Pregnancy Act 1971 and Medical Termination of Pregnancy Rules 1975.
Geeta Sodhi, Study on Informal Providers of Abortion in Tigri Resettlement Colony, Delhi, SWASTHYA, New Delhi, 2003.
Ganesh Pandey, A Qualitative Study of Informal Providers of Abortion in Maitha Block, Kanpur , Shramik Bharati, Kanpur, 2003.
Sandhya Barge, Wajahat U. Khan and Yamini Venkatachalam, Role of Informal Providers of Abortion: A Case Study of Two Villages in Jind District, Haryana, CORT, Baroda, 2003.
Alex George, Informal Providers of Abortion Care in Two Blocks of Madhya Pradesh and Social Perception About Them, Centre for Health and Social Sector Studies (CHSSS), Secunderabad, 2003.
Shyam Ashtekar, Informal Providers of Abortion in Nasik, Bharat Vaidyaka Sanstha, Nasik, 2003.
H. Sudarshan, Study of Informal Providers of Abortion Care in Rural Karnataka, VGKK, Chamarajnagar, 2003.