Accessibility and utilization
SANDHYA BARGE, WAJAHAT ULLAH KHAN, SEEMA NARVEKAR and YAMINI VENKATACHALAM
THE Medical Termination of Pregnancy (MTP) Act was implemented in India more than three decades ago to curb the high number of clandestine abortions and reduce the high rate of maternal deaths caused by such abortions. The act thus came into existence to ensure women’s access to safe abortion services by bringing medical termination of pregnancy into institutional settings where adequate equipment, medical supplies and specially trained personnel are in position.
The MTP Act defines the place, person and the conditions under which a pregnancy can be terminated. Under the act, abortion can be provided only by a registered medical practitioner (with a degree in allopathic medicine) who has the necessary qualification, training and experience in performing MTP and only at a place which has the facilities, meeting standards specified in the Rules and Regulations of the MTP Act. Thus, abortion carried out by persons and at places not registered or certified under the MTP Act is illegal.
Over the years, there has been an increase in the number of legal, that is, registered health facilities to provide MTP – from 1,877 in 1976 to 8,722 in 1995-96. However, as an earlier study of government facilities registered to provide MTP revealed, not all registered facilities are also functional (Barge et al. 1998). Thus, safe abortion services continue to be inaccessible to women, particularly to those in the rural areas where they are most needed. In order to ensure that women who desire termination of unwanted pregnancies have easy access to safe and hygienic facilities, we need to know what type of facilities are available, whether they are adequately equipped and how well they are utilized. Such information would help strengthen existing MTP services in the country.
This paper attempts to answer these questions. It draws predominantly on the findings of a recent situation analysis of facilities where formal providers (one who is trained in medicine from a formal institution that awards a degree in medicine) were performing MTP. The situation analysis was conducted by six research agencies under the National Abortion Assessment Project in two districts each of the states of Haryana, Kerala, Madhya Pradesh, Orissa, Rajasthan, and Mizoram (SORT 2003, ACHMSS 2003, CHSS 2003, CINI 2003, ARTH 2003, OKDISCD 2003). In each of these districts, the study was conducted in three administrative blocks (a block covers approximately 100,000 population).
In addition to the findings from the situation analysis, data was drawn from a study of MTP facilities conducted by the Centre for Operations Research and Training (CORT) in six districts of Rajasthan (CORT 2003). Both studies covered all government facilities up to the primary health centre level and private clinics that were currently providing MTP services in the study areas. The study protocols used in all study sites were uniform. Three different types of structured questionnaires – for the provider, administrator at the facility and a checklist – were administered. Data collection in all the above mentioned states was carried out during 2001-2002. The discussion in this paper is based on the analysis of data only from facilities for which a complete set of data collected through all the three study protocols was available. Data from 414 facilities covered in all the states have been analyzed and discussed.
In the Indian health care system, the public sector provides health services through a three-tier network of health facilities consisting of the primary health centre (one for 30,000 population), community health centre (one for about 100,000 population), district hospital (one for two million population) and a teaching/tertiary hospital. With this vast network, government facilities are the most accessible source of health care to the rural communities. Under the MTP Act, 1971 a hospital established or maintained by government is recognized by default as an authorized place to provide MTP services. In contrast, private hospitals and clinics need government approval and authorization (certification) to provide MTP services. The private clinics receive their certification only if the government is satisfied that ‘termination of pregnancies may be done under safe and hygienic conditions,’ and the clinic has the requisite infrastructure and instruments in place.
Despite the existence of a well-integrated network in the rural areas and their authorization by default to provide MTP services, the number of government health facilities providing these services is low. Of the 414 facilities providing MTP services in the study area, only 108 are government facilities, the rest (306) being private.
Though certification of the health facility is a requirement under the law for facilities in the private sector, in reality not all private clinics adhere to the law. Among the 306 private clinics currently providing MTP services, only three out of every ten facilities are certified. The rest are providing MTP without certification and, therefore, the abortions performed at these clinics are illegal. Some of the common reasons stated by the non-certified private facilities for not getting themselves registered were: ‘no need for registration’, ‘have trained provider’, ‘no particular reason/never thought about it’, ‘no knowledge about it’. This underscores the need for creating awareness among providers about the requirement of place and provider certification under the law.
Distribution of both government and private MTP facilities across the various study states is unequal for which there is no rationale. For instance, in Orissa only 7% of the total facilities are government, while the number is 38% in Rajasthan. In Mizoram, which is a relatively smaller state, MTP services were provided predominantly (84%) by government facilities. In the case of certified private facilities, their distribution across the states varies from a high of 57% in Rajasthan, followed by 36% in Kerala, 27% in Madhya Pradesh, 19% in Haryana, to as low as 4% in Orissa. In Mizoram only two out of the four private clinics covered were certified.
In terms of physical accessibility and infrastructure, nine out of ten private facilities were strategically located, on the road, whereas 83% of government facilities were so placed. Private certified clinics had relatively better logistics – seating arrangement for clients, sheltered waiting area, auditory and visual privacy during consultation and visual privacy in the recovery room – than government and non-certified private facilities. The availability of supportive equipment was better in the private certified facilities.
Methods of abortion vary depending on the stage of pregnancy. Methods used to terminate pregnancies of the first trimester (up to 12 weeks of gestation) are relatively simple and require less supportive equipment as compared to the methods used to terminate second trimester pregnancies (13-20 weeks of gestation). A majority of the facilities (67% government and 76% private) provide MTP services only for first trimester pregnancies. MTP services for the second trimester, which require relatively more supportive equipment, were provided by only one-third of the government facilities and 24% private facilities. Among private facilities, 65% of the private certified facilities were providing first trimester services, while the figure was as high as 81% among the private non-certified facilities. This indicates that private non-certified facilities do not want to risk performing second trimester abortions either due to inadequate equipment or because their providers lack the necessary skills.
Among the first trimester methods like manual vacuum aspiration (MVA), electric vacuum aspiration (EVA), dilatation and curettage (D&C), D&C continues to be the most commonly used method, though the WHO (2003) strongly recommends that all possible effort be made to replace sharp curettage with vacuum aspiration. The recommended surgical method of abortion for the first trimester is either manual or electric vacuum aspiration. D&C, which has a higher risk of complications, blood loss and longer recovery time, should be used only in the absence of other safer methods.
Each method of abortion requires a basic set of instruments and equipment. In its absence, the provider may compromise the quality and still perform MTP. Information on the availability of complete sets of D&C, MVA and EVA showed that around two-thirds (65%) of the facilities had a complete set of D&C instruments, while 32 and 40% of the facilities had a complete set of MVA and EVA instruments respectively. In this case too, private certified facilities were relatively better equipped than government ones with a complete sets of instruments required to carry out different procedures like MVA (43% private certified vs. 22% government), EVA (51% private certified vs. 25% government), and D&C (78% private certified vs. 63% government).
Further, in order to deal with complications it is important that the facility has instruments for more than one method of abortion. Analysis of the number of methods available with complete set of instruments in the facility shows that 35% of them did not have a complete set of instruments even for one method of abortion, 23% had a complete set available for one method, 12% for two methods and 30% to provide three methods. Clearly, some facilities are performing MTP procedures even in the absence of a minimum set of instruments required for the procedure, compromising the quality of service.
So, who are the providers performing MTP at these facilities? The MTP Act clearly lays down the experience and training requirements a person needs to fulfil for eligibility: only a medical practitioner who is registered in the State Medical Register and has training in gynaecology and obstetrics, or a registered medical practitioner who has received training for conducting medical termination of pregnancy from a hospital recognized for the purpose by the government. In the 414 facilities, 504 providers perform MTP and their average age was 43 years; 59% were females and 42% males. It is interesting to note that providers in private certified facilities are predominantly females (81%), whereas there is an almost equal distribution of male and female providers in the government facilities.
Over half (55%) of these providers are obstetricians/gynecologists, and in private certified facilities they account for 77% of the providers with the above qualification. Even in the non-certified private facilities, 47% of the 245 providers interviewed were obstetricians/gynecologists. In other words, the abortions performed at these non-certified facilities, though done by trained doctors (as required under the MTP Act), are illegal as these facilities are not certified. Similarly, the services provided by 25% doctors in these non-certified private facilities, who are trained in Indian systems of medicine (ayurveda, unani, homeopathy) and are currently providing MTP services, are illegal, because the MTP Act does not recognize them as formally trained MTP service providers.
Out of the 504 providers, 359 (71%) had the necessary formal training and experience as specified in the MTP Act; in the government facilities, 79% of the providers had formal training, while in the certified and non-certified private facilities 95% and 56% respectively had formal training. This clearly shows that certification of a facility for MTP services does not necessarily ensure that the services will be provided by a trained provider and vice-versa, that is, the providers in non-certified facilities are not always untrained.
The abortion method that a provider generally uses depends on his/her skill as well as confidence in providing the method. As data reveals, none of the providers had confidence in any single method – it varied across methods. The providers are more comfortable in providing first trimester methods, as 72% mentioned having confidence in performing D&C, followed by EVA (56%), and MVA (52%).
Around 65% of the providers were confident to provide dilatation and evacuation (D&E), but confidence in the use of extra-amniotic and intra-amniotic methods that are second trimester methods was less at 37% and 25% respectively. To an extent, providers from private certified facilities were relatively more confident than their counterparts in the private non-certified and government facilities. Considering the higher level of confidence among the providers in conducting D&C and that it is the most commonly used method of abortion in all the facilities, it may be concluded that providers use the method they are most comfortable with.
Besides maintaining medical standards in conducting safe abortion procedure, providing information to the client is an essential part of good quality service. Information must be complete, accurate and easy to understand, and be given in a way that respects the woman’s privacy and confidentiality (WHO 2003). According to WHO, the issues on which a woman should be informed are: what will be done during and after the procedure, what she is likely to experience (e.g. cramps, pain and bleeding), how long the procedure will take, what pain management can be made available, risks and complications associated with the method, and when she will be able to resume normal activity, including sexual intercourse and follow-up care.
But, as evident from the data, providers do not talk about all the above mentioned issues. For instance, as part of pre-abortion counselling, only 67% informed their clients about the pain/discomfort during procedure and how it could be minimized, and 78% talked about possible complications. The instructions to their clients at the time of discharge were mainly ‘advice on follow-up visit’ (73%), ‘what problems to expect’ (54%), ‘danger signs and what to do about them’ (56%), and ‘how to take the prescribed medicine’ (60%). Very few advised their clients when to resume sexual intercourse (6%).
Despite having infrastructure and trained providers, about 60% of the facilities sometimes referred abortion clients to other facilities as they could not handle all the cases themselves. The types of cases mainly referred relate to: ‘pregnancy above 12 weeks’ (74%), ‘women with medical risk factors’ (51%) and ‘incomplete abortion induced elsewhere’ (26%). The facilities where cases get referred are generally the higher referral government facilities in the case of government facilities and even private facilities refer cases to a government facility existing in their respective areas. Only 9% of the private facilities reported refering clients to another private facility.
Utilization of the MTP facilities in the three months preceding the survey was on an average 34 abortion clients per facility. It is often claimed that the utilization of services of facilities that are accessible and well-equipped in terms of infrastructure and logistics is usually higher. As discussed earlier, private certified facilities were better equipped than government and private non-certified facilities. Interestingly, however, government facilities drew more clients (48.6) than did private clinics (29.1). Among the private facilities, the average number of abortion clients reported in certified private facilities was 41, whereas it was nearly half of this at 24 in non certified facilities. Most women seeking MTP services at these facilities had a gestation period of 12 weeks or less. The average number of clients seeking the abortion services up to 12 weeks was 30, whereas about 14 clients sought second trimester services.
The cost that clients incur for services varies both by the gestation weeks and by the type of facility from where services are sought. For instance, the minimum and the maximum cost reported for the first trimester ranged from Rs 526 to Rs 788 and for second trimester abortion from Rs 796 to Rs 1203. Apparently, the cost incurred for services was the highest in private certified facilities, followed by private non-certified facilities and the least in government facilities. In government facilities no major difference was observed between the costs mentioned for first trimester abortion (minimum Rs 262 and maximum Rs 469) and second trimester abortion (minimum Rs 305 and maximum Rs 513). This might explain the higher utilization of government facilities, despite their not being as well equipped or accessible as the private ones.
There is a demand for both abortion services and treatment of post-abortion complications in the community. In addition to receiving clients for abortion services, close to eight out of ten facilities also received cases of post-abortion complications for treatment. The average number of clients received in the three months preceding the survey was seven each in government and non-certified private facilities, while it was six in the private certified facilities. The types of post-abortion complications that clients mainly seek treatment for are: ‘incomplete abortion (79%), hemorrhage (43%) and septicemia (34%).’ This indicates that these women had probably undergone abortion from untrained personnel outside the formal sector, as abortion complications if performed by appropriately trained personnel in safe and hygienic condition, are rare.
This preliminary analysis of MTP facilities across the various states of India brings out several important findings. The demand for abortion services in the community exists and hence those in need approach a facility regardless of whether the facility/provider is legal or not. The proportion of certified facilities is small, but the services being provided by non-certified facilities does not necessarily mean that these are being provided by an untrained person. A mechanism has to be developed to monitor the quality of MTP services being provided even by the government and certified private facilities. Providers need to be continuously trained for alternative and safer methods of abortion, including counselling, in their package of services.
Abortion clients spend a substantial amount on MTP services even at government facilities, which are expected to provide them free of charge. Government facilities, though overshadowed by private sector abortion facilities and providers, continue to serve as a referral point, including the private sector, for the treatment of complications.
All of the points discussed above corroborate the findings that had emerged from an almost similar, pioneering study of MTP facilities carried out by CORT in the states of Gujarat, Maharashtra, Tamil Nadu and Uttar Pradesh (Barge, et al. 1998). It shows that the availability and quality of MTP services has remained the same over the years, irrespective of regional differences in the states. Though the situation has not improved over time, a conducive climate has been created to review abortion policy, law and service delivery in India. Conscious efforts are now being made to bring abortion services back on the agenda of the health services.
Discussions and debates among policy-makers, researchers, providers and other advocates have led to some amendments in the MTP Act. The recent amendment of June 2003 has simplified the registration process for private clinics by decentralizing the process as well as evolving separate registration procedures for facilities providing abortion services up to 12 weeks and those providing services for 12-20 weeks gestation. The amendment has also included medical abortion in the purview of the MTP Act. This should facilitate the so-called ‘illegal formal provider’ to come under the category of legal provider, in turn improving women’s access to safe abortion services.
Achuta Menon Centre for Health Sciences Studies (ACHMSS), Situation of MTP Facility in Kerala (monograph), Trivandrum, 2003.
Action and Research for Training in Health (ARTH), Situation of MTP Facility in Rajasthan (monograph), Udaipur, 2003.
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Centre for Health and Social Sector Studies (CHSSS), Situation of MTP Facility in Madhya Pradesh (monograph), Secunderabad, 2003.
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Child in Need Institute (CINI), Situation of MTP Facility in Orissa (monograph), Calcutta, 2003.
Omeo Kumar Das Institute of Social Change and Development (OKDISCD), Situation of MTP Facility in Mizoram (monograph), Guwahati, 2003.
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