A provider’s perspective
THE causes of maternal deaths and ill health are multiple. Unfortunately, despite legalization of abortion over three decades back, one main reason women in our country continue to die is because they seek to end unwanted pregnancies but lack access to appropriate services. In our attempt to reduce levels of maternal mortality by three-quarters between 1990 and 2015, as agreed by India at the United Nations Millennium Summit held in October 2000, or bring the MMR ratio of 407 per 100,000 live births to below 100 by 2010 as per the national socio- demographic goals set in the National Population Policy 2000, we need to seriously address the issue of unsafe abortions.
Fortunately, deaths and complications from unsafe abortion are preventable. The procedure and techniques for early abortion are simple and safe, particularly when performed by a trained provider with proper equipment, correct technique and sanitary standards. Simultaneously, there is need to ensure that the abortion rate declines sharply by making contraceptive methods (including emergency contraception) attractive, available and widely used. But we must also understand that even in countries where effective contraception is widely used, for several reasons nowhere has abortion rate declined to zero. Thus there will always be need for safe abortion services.
Parivar Seva Sanstha, established as an NGO in 1978, chose abortion as its thrust area when it set up its first Marie Stopes Clinic in New Delhi. Although the Medical Termination of Pregnancy Act 1971, strongly backed by the medical fraternity, had come into force on April Fools Day in 1972, the situation remained grim. Doctors continued to be blatantly confronted with gravely ill or dying pregnant women whose uterus had been tampered with a view to causing an abortion. The reason being that although an act had come into force, the social realities had not been addressed by policy-makers since abortion continued to be stigmatized and both the providers and abortion seekers remained ignorant of its legalized status. The situation was even more grim as both officials responsible for provision of services as well as the law enforcing authorities not only continued to remain ignorant of the act, but often imposed their personal views in a gender discriminatory manner. It was, therefore, important to bring abortion out in the open.
Parivar Seva through its advocacy efforts – among the women, their influencers, providers, media and policy-makers – played an important role in sensitizing them regarding legality and safety issues pertaining to abortion. It also demonstrated, through its model MTP clinics, that confidential, compassionate, simple but quality abortion services provided on a walk in out-patient basis are not only convenient to the woman and her family, but greatly reduce the cost of services. The addition of post-abortion family planning services further helped to greatly reduce the need for repeat abortions. Soon, all other reproductive health services such as antenatal and post natal care, screening for reproductive tract infections, infertility treatment and immunization, were added to make the services holistic and integrated.
The current situation in our country, although still unacceptable as abortions continue to be unsafe and illegal, is a vast improvement over the earlier days. Certainly, as envisaged, the MTP Act has contributed significantly to save the pregnant woman’s health, strength and often life. However, even today, of the estimated 6.7 million induced abortions in the country, only about six lakh reported legal abortions take place, a figure that has stagnated over several years now (despite an enlarged base of reproductive age population), except for two years when it crossed seven lakh. It is worth noting that of this figure, Parivar Seva alone, through its Parivar Seva/Marie Stopes clinics in selected locations, accounts for about 13% of all reported cases in the country.
Based on our understanding of the overall situation in the country, we assess that another 2.6 million abortions are possibly performed by providers who though not legally recognized, have some basic knowledge regarding pregnancy and the abortion procedure. This leaves a balance of 3.5 million abortions that are performed by totally untrained personnel or the woman herself – at great risk to the lives of women.
This pathetic situation results from a lack of knowledge regarding the legal status of abortion as well as insufficient access to safe, quality, legal and affordable abortion services and because of lack of availability of recognized service delivery centres and competent service providers ensuring confidentiality and compassion. The most to suffer are unmarried young girls and widows. Despite a liberal law, they face social discrimination and are exploited by the providers who charge exorbitantly for abortion services.
Parivar Seva, through its 38 full-fledged reproductive health clinics, provides over 78,000 abortions annually. As a result, it has gained valuable insight and experience in this sensitive area of reproductive health care. In addition, several baseline and research studies have been carried out by Parivar Seva, both by its own research department as well as by engaging the services of other professional agencies and lessons fed into the system to further improve services. It is, therefore, no surprise that our client base is constantly increasing and referrals to our clinics from satisfied clients forms the major basis of our clients. It is satisfying to note that although Parivar Seva/Marie Stopes clinics are located in cities and smaller towns, we cater to a large percentage of rural clients who travel long distances to avail of quality service.
Our typical client is a married woman with one child who has not used a contraceptive method earlier because of the myths associated with it. Economically and health-wise, she is not in a situation to go through another pregnancy. Above all, she and her family are concerned about the consequences of another full pregnancy and child birth on the health and well-being of the current small child who first needs nurturing for proper growth and whose survival is often at stake. Most of our clients, on counselling, which is our unique service, easily accept a suitable family planning method, thereby ensuring proper spacing until the next child and safeguarding the health of both the mother and child for a reasonable period.
It is our attempt to widely promote reversible methods of contraception to eligible couples so that the need for abortion does not arise. This is being done through our contraceptive social marketing programme where we sell branded condoms and oral contraceptive pills. We also make available injectable contraceptives, as many of the women we encounter are lactating and this contraceptive, while offering protection from pregnancy, does not reduce the flow of milk for the baby.
For those who have completed their family, prompt provision of abortion services gives them another choice of method. Parivar Seva has recently introduced a dedicated emergency contraceptive ( NoPreg) which should further help to ensure that unprotected sex or improper method usage/failure does not result in an unwanted pregnancy.
Since its inception Parivar Seva has played a pivotal role in improving delivery of abortion services in a client-oriented manner. The Manual Vacuum Aspiration (MVA) technique has been perfected by Parivar Seva since its introduction in 1979. It is a matter of great satisfaction that due to the advocacy efforts of Parivar Seva and other organizations, the government has now introduced this method of terminating early pregnancies on a pilot basis in primary health centres in selected districts of eight states. The aim is to make this simple technique available at the lowest public sector delivery site so that there is wide accessibility of abortion services. This strategy needs to be tried out urgently to enable all sector PHCs in the country to deliver this service.
For late gestations (16-20 weeks), Parivar Seva has also perfected the technique of dilation and evacuation. This two stage procedure has been evolved keeping in view the convenience of the client and her mental state. Parivar Seva is also carrying out operation research studies on client acceptability of medical abortions in eight of its clinics. The success and acceptability has been very good. However, it is our concern that the drugs for this method, if directly available to the client from the chemist, may lead to unnecessary experimentation, negative consequences and the likelihood of a good method under medical supervision losing its reputation due to mishandling. This needs to be carefully monitored by the authorities.
Another important development subsequent to the technical workshop ‘to make early abortions safe and accessible’ organized by Parivar Seva in collaboration with MOHFW, GOI and Ipas in October 2000 in Agra, has been the recognition that abortions up to 20 weeks should not be treated as one category. Since the infrastructure and provider training required for early and late abortions is quite different, there is need to separate the gestation in two groups – one up to the first trimester (12 weeks of gestation) and another second trimester (above 12 weeks to 20 weeks of gestation).
As a result, the rules under the MTP Act were modified in June this year, which clearly recognized the distinction between first and second trimester abortions, medical abortion as a procedure included, and the registration process was simplified. It is hoped that as a result, registration of facilities providing abortions in the simplest settings would improve and women’s accessibility to legal and safe abortions greatly enhanced.
In order to facilitate the above process, initiatives are now required at the state level to translate the policies into action. Clear guidelines from the Ministry of Health and Family Welfare, Government of India, currently under preparation will go a long way to help the states to better understand policy and implementation issues.
It is important that the state governments disseminate the details of changes in the MTP Act and Rules to the chief medical officers in the districts, who now have the decentralized power to grant recognition to private clinics with the help of local committees. In August this year, with support from the Central Ministry of Health and Family Welfare and Government of Rajasthan, Parivar Seva was able to facilitate a dissemination workshop for the concerned state and district level officials in Rajasthan. Through participatory involvement, a complete stock of the situation was taken and specific action plans finalized for making abortions safe and legal in the state, with a view to decrease the high maternal mortality and morbidity. Earlier, we had successfully carried out a similar effort for the Orissa government and would be happy to facilitate the process in other states too.
Availability of trained providers has been a major constraint in making available safe abortion services. As the public sector has not been able to fulfil this task, there is a need for private-public partnership in this area. A large number of doctors, both within Parivar Seva and outside, including government doctors in different parts of the country, have been trained in our clinics. Our Karol Bagh clinic, located in New Delhi and recognized as an MTP training centre, has issued certification to several doctors. However, there is a vast untapped potential for a good training centre and it is necessary to set up a free or heavily subsidized training facility so that a large number of trainees could be imparted ‘hands on’ training.
It would also be worthwhile for state governments to consider ‘buying’ abortion and family planning services from well-established NGOs, particularly to meet the needs of those below the poverty line. This would free them to handle more complicated cases while simultaneously helping clients receive compassionate quality services. Such an arrangement in Balasore district in Orissa with Parivar Seva clinic is working well.
Several research studies have shown that most women, and particularly their husbands, who are the actual decision-makers regarding whether or not to keep an unwanted pregnancy and even the choice of providers, are unaware that abortions are legal for all women irrespective of marital status, age, religion and caste. There is a need to carry out educational and communication campaigns in local languages to inform the community as well as the providers regarding conditions when abortion is available. Also to inform the women that in case they wish to terminate pregnancy, they must come soonest as early abortions are definitely safer. Alongside must be included messages regarding post abortion family planning acceptance so that the need for abortion is reduced. Involvement of men in such campaigns is sure to yield better results. Another area requiring attention is meeting the reproductive health needs of adolescents and youth.
Parivar Seva has carried out effective campaigns regarding safe abortions in the areas where it has its clinics. Initially, we faced tremendous opposition from the media who refused to carry our advertisements. The situation has now improved, but there are some newspaper and other media who still refuse to accept our promotional work.
Our promotional work has been done with limited finances as this forms just one line item in our clinics’ budgets. Though more effective, because of financial constraints we have used the electronic media in a limited manner, but have widely used newspapers, magazines, wall paintings, hoardings, kiosks and so on, in addition to interpersonal communication using our team of health workers. As a result, we have developed a large network of referrals from the community – doctors, chemists, ANMs, aganwadi workers and other leaders in the community. Mobile campaigns with strong interpersonal communication, besides appropriate software, were found effective. In all our campaigns we have used an integrated approach to reproductive health, of which abortions forms only one component.
In addition to specific campaigns carried out for our own clinics and projects, we have recently successfully executed, in close collaboration with the Government of Orissa, a major generic multimedia campaign on different aspects of reproductive health. Safe abortion was an integral and important part of this campaign. Executed totally in Orissa, with intense local participation, this campaign lasting just over a year created huge awareness among the target audience. This was borne out through surveys, carried out as baseline and at the end of the campaign. Such efforts are required in all the states and particularly in the eight empowered action group (EAG) states identified by the government for intensified working.
PSS has also worked at the international level to make abortions accessible and safe for women the world over. This was particularly important as the American Gag Rule served to deny this basic health service to women in the developing world by imposing unfair restrictions, even where abortion was legal. One important contribution by Parivar Seva was to participate and intervene in a WHO meeting in Geneva in September 2000, resulting in the Technical and Policy Guidance for Health Systems for Safe Abortion, in 2003.
Parivar Seva Sanstha, an Indian NGO, working in 21 states in the country in the area of reproductive health for the last 25 years, is a non-profit registered society. We are mainly an implementing organization and take pride in delivering projects in time and within budgets, while maintaining high quality standards. PSS also carries out research, consultancy and training. Its three thrust areas are social marketing of clinics, social marketing of contraceptives, and reproductive health education and training.
We currently have 43 clinics; of these, 41 clinics are mainly for women (although specific services for men and children are also available) – 38 Marie Stopes/Parivar Seva clinics are full-fledged integrated reproductive health care services and three satellite clinics. Two are exclusively innovative clinics for men, branded as purush.
Parivar Seva provides affordable quality abortion services to fill the gap between free hospital services and the highly priced nursing home services. Recognizing our efforts, the Government of India from as far back as 1987 had extented financial support to operate 10 model clinics in different states. Non-judgmental counselling, warm atmosphere and quality ensures an ever-increasing base of satisfied clientele and a strong referral network for our services.
Our second thrust area is contraceptive social marketing, which uses the proven tools of commercial marketing (techniques, mass media and existing commercial channels) for high efficiency, low cost delivery of essential social needs. Under the social marketing umbrella of GOI, we market three brands of condoms – Sawan, Milan, and Bliss and an oral contraceptive pill Ecroz. We sell over 55 million condoms and three million OCPs per year.
Our third thrust area is reproductive health education and training, where reproductive and sexual health needs of adolescents and youth are addressed through educational programmes. We work directly or with other NGOs in the community as well as in schools, colleges and industry.
We judge our performance in terms of couple years protection provided by us through our programmes. We are providing about 11 lakh Couple Years Protection or CYPs per year – with a cumulative CYP of 1.03 crore since inception.
While improving maternal child health, Parivar Seva is simultaneously contributing to stabilize the population in the country.