Community Based Study of Rural, Tribal Women Seeking Induced Abortions in a Extremely Low Resource Region

WHO reported that globally around 42 million pregnancies were voluntarily terminated each year, 22 million within the legal system and 20 million by unskilled providers and/or in unhygienic conditions¹. Dr Bela Ganatra, scientist in the WHO Reproductive Health and Research Division and lead researcher of the related study, said , ‘Increased efforts were needed, especially in developing regions, to ensure access to contraception and safe abortion’². A study revealed that of 6.4 million abortions performed in India between2002 – 2003, 3.6 million (56%) were unsafe and only 10% of induced abortions were being reported¹. Evidence revealed that majority of the IA were performed in private facilities and remained unreported. Malhotra reported that in Madhya Pradesh of India, more than half of all the abortions among urban women took place in the private facilities³. Community-based information is lacking about IA sought by rural tribal women. However, it is essential to know the ground realities for appropriate services, programmes and policies.

Community based study was carried out to know magnitude of IA sought by rural tribal women, their demography, reasons, places of services and persons performing IA.

After taking institute’s ethics committee’s approval community based study was carried out in 118 villages with population of around one lac and ten thousands,53 villages were near Sewagram village in Wardha, 65 villages in Melghat region of Amravati of Maharashtra, India. Predesigned tool with locally used language was used to get needed information after taking consent. Study subjects, women of 15-44 years were interviewed by field assistants by visiting every fourth house in the villages. If there was no case of IA in fourth house, next and next was visited. Women who had IA in last 5 years (to avoid memory bias) were study subjects. Interviews were conducted one to one, either in the woman’s house or in near-by Anganwadi (place of mother child care) as per the convenience of research assistants and study subjects. Interviews were conducted for around 30 minutes to one hour each, depending on how much time, women took to respond. No one was forced, but no woman who could be part of the study refused interview. Women were asked about demographic characteristics, (age, parity, literacy, economic class), reasons for seeking IA, duration of pregnancy at which abortions were sought, methods of abortions, places of abortions, and persons conducting abortion. Responses were recorded on the hard tool by research assistant. No one was given tool to fill. Focus group discussions (FGDs) were also held, with no age bar and whether women themselves had abortion or not. Whosoever was willing was invited, 8-15 women in a group. The same tool which was used for interviews of the study subjects was used for FGDs with changed in language in FGDs.

In villages near Sewagram 726 women had abortions. Of them 177 had IA (24.3% of all abortions). Of all the women who sought IA, 43% were of 25-29 years and 23% of 20-24 years. In villages of Melghat, 1244 women had abortions and of them only 27 had sought IA (2.1% of all abortions), 39% women were of 25-29 years and 42% women were of 20-24 years, significant difference between two sets of villages in the same state (p value=0.0018).Teenage girls were also significantly more in Melghat region (4%) compared to Sewagram region (0.6%), (P value = 0.0014). More rural women of villages near Sewagram who had IA were of advanced age (35-39 yrs and 40-44 years), than Melghat (7% versus 2.6%). Most of the women who had IA had only primary schooling in both the districts, however, significantly more women were illiterate in Melghat region (19%) than in villages near Sewagram(2.6%) (P value<0.05). Number of graduate women was small in both the sets of villages, among all those who had sought IA, still in Sevagram region had significantly more were graduate studied (8%) than Melghat (1%) (P value <0.05). There was no difference in education of women who had IA or no IA but between villages of two districts, there were differences. Around 6% women were from low economic class in villages near Sewagram, but in Melghat region 68% were from low economic class, highly significant difference (P value= 0.0018). In women of villages near Sewagram 43% and in Melghat region,16%were of low middle economic class⁴(P value<0.05). In villages near Sewagram, 64% women were house wives and 35% unskilled workers and in Melghat region, 71% were unskilled workers and 26% housewives (P value<0.05). There was no difference in these variables in women who had IA or did not have IA. There were more women with two births, who had sought IA in villages near Sevagram (46%) compared to villages of Melghat (28%). Second gravida and third gravida were of almost similar number in both the districts, however fourth gravida were more in Melghat region(6.4%) compared to Sewagram region (1.1%).

In Sewagram region, 45% women had two births and 0.8% had four births and in Melghat region, 27% had two births and 6.5% had four births, significant difference. There was no evidence of sex selective IA in both the sets of villages.

Over all of 177 women of villages near Sewagram, only 9 (5.0%), had IA for pregnancy of less than 6 weeks, 73 (41.2%) 6-9 weeks, 79 (44.6%) 10-13 weeks, 11 (6.2%) 14-17 weeks and 4(2.2%) for 18- 20 weeks pregnancy too. Quite a few (more than 50%) women had IA for pregnancy of 10 weeks or more. Even in villages near Sewagram with 2 Medical colleges in the district, many women sought IA from private hospitals(PH)(103(58.1%)), 41 (23.1%) at MC,12 (6.7%) at Primary Health centers (PHCs), 7 (3.9%) at District hospital (DH), 7(3.9%) at Sub-centers (SCs), and 7(3.9%) at Home also. Overall 97 (54.8%) women had sought IA for spacing and 8 (4.5%) because of poverty. Twenty-seven (15.2%) women reported contraceptive failure. Overall 42(23.7%) women reported health issues and 3(1.6%) had other reasons. Six (3.3%) women had self-IA with some traditional items. One (0.5%) more had IA with the help of a traditional birth attendant. So overall 4% IAs could be called unsafe in rural communities of Sewagram region. Overall 100 (56.4%) women said abortions were performed by general medical officers and 70 (39.5%) by specialists at different health facilities. Methods for IA were medical in 135 (76.2% out of 177), and surgical in 41(23.1%). Of the 177 women who had IA, 7 had two abortions, 3 (42.85%) between 6-9 weeks gestation and 4 (57.14%) between10-13 weeks. The places of abortions were PH in 4(57.14%) and MC in 3 (42.85%). Five (71.42%) women said they had IA for spacing and 2 (28.58%) because of poverty. Five (71.42%) women’s IA were performed by medical officers and 2 (28.57%)by specialists.

Of the 1244 women who had abortions in villages of Melghat region in Amravati district, only 27(2.1% of all) had IA, 12(44.4%) for pregnancy of 6-9 weeks, 13(48.14%) of 10-13 weeks, one( 3.7%) of 14-17 weeks and one (3.7%) of 18-20 weeks. Most of the women (17 (62.9%)) had IA at PH, 2 (7.4%) at MC, 4 (18.5%) at SC, one (3.7%) at PHC, and one at (3.7%) DH. Seven (25.9%) women reported IA for spacing, one(3.7%)for poverty and 2 (7.4%) reported contraceptive failure. One (3.7%) said she had health problems and 16 (59.2%) had other reasons for seeking. Overall 12 (44.4%) women said IA were performed by medical officers and 15 (55.5%) by specialists. Reported methods used for IA were medical in 17 (62.9%) and surgical in 10(37.03%). No woman reported anything which could be called unsafe practice for IA in the villages of Melghat. Also there was no severely ill woman, no near miss and no abortion related death in these villages over these years.

During FGDs which were conducted with group of 8-15 women irrespective of their age or whether they themselves had abortion or not, wide range of views were reported. However there was much more ignorance, lack of awareness about IA with their own beliefs in villages of Melghat region, than in Sevagram region. Even worldly wisdom which had some science, was in much less women of Melghat region than in Sevagram region. There were more misconceptions and very little awareness for prevention of unwanted pregnancy and unwanted births, in the women in these villages more so in Melghat region.

Community based study of magnitude of IA sought by rural tribal women in some villages of two districts of Maharashtra, India was carried out to know the magnitude, socio demographic characteristics, reasons for IA, duration of pregnancy at abortion, places, and methods of induced abortions. In Melghat region, there were access problems, lack of resources, lack of awareness and scarce health services. Study revealed that there were no differences in demographic features among women who sought IA or not. However there were significant differences between women of villages near Sewagram who had sought IA and in Melghat in the same province. The number of IA were much less, around 2% of all abortions in Melghat region compared to 24% in Sewagram region. Probably women in Melghat region had no thoughts of planned family, so did not think of IA to prevent unwanted birth. If pregnancy occurred they just continued. It was revealed that in villages near Sewagram region, 43% women who had IA were of 25-29 years, 23% were of 20-24 years.

In Melghat region,39% women were of 25-29 years and 42% were of 20-24 years, significant difference in two sets of villages. Teenage girls were also more in Melghat region compared to Sewagram region. However advanced age women were more in Sevagram region than in Melghat. Most of the women who had IA had only schooling in both the districts, however significantly more women were illiterate in Melghat. Number of graduate and educated women was low in both the sets of villages but there were significantly more graduates among women who had sought IA in Sewagram region than Melghat. Around 6% women were from low economic class in Sewagram villages, 68% in Melghat region, highly significant difference. In a study conducted by Kant et al⁵, the odds of having an IA declined with the declining economic status as reflected by the wealth index, similar to the present study. In villages near Sewagram, 64% were house wives and 35% were unskilled work errand in Melghat region 71% were unskilled workers and 26% housewives.

There was significant difference in parity in women in both the regions who had IA. Significantly more women with two births in Sevagram region had sought IA compared to those in Melghat region. Fourth gravida were significantly more among women who had sought IA in Melghat region compared to Sewagram (1.1%). There was no evidence of sex selective IA in both the districts. In Melghat region there was more poverty, lack of resources, infrastructure compared to Sewagram region. In Sevagram region most of the women had IA for spacing with no use of contraceptives. In Melghat region 59.2% women had other reasons, 25.9% for spacing and 7.4% for failure of contraception. Poverty and poor health were other reported reasons. The reasons for IA varied in different studies and included socioeconomic concerns. However, the major underlying causes reported have been unawareness or lack of access to contraceptives. In a study conducted by Tesfaye et al⁶ in Ethopia, the main reasons for IA were found to be for completion of education in 40.8% and economic reasons, 36.7%. More than three-fourth (75.5%) women reported pregnancies unwanted because of forgetting to take contraceptives as the main reason. In the present study most IA for unwanted birth were for spacing, mostly with no use of contraception. In Sewagram as well Melghat region, most women sought IA from PH 58.2% and 62.9% respectively, though most women were poor. In Melghat region there was visible extreme poverty. Abortion being a very personal private affair women preferred private centers even with extreme poverty. In Melghat region 44.4% women had IA performed by Medical officers, 55.5% by Specialists, Nurse Midwives helped women to have IA at PHC by medical means with privacy. Unmet need was high. Awareness, access, less resources and availability seemed to matter a lot in seeking services for abortions but secrecy and privacy seemed most important for selecting the health facility for abortion. Policy makers needed to know. It seems that a lot of research is needed about abortion seeking practices. IA seeking differed in the same state with different populations, probably awareness, access, resources and felt need for planning family affected decisions of IA. Probably women allowed unwanted pregnancy to continue in Melghat as there were many women with 4 births.

It is well known that abortion is much safer around 8 weeks than in second trimester. In Sewagram region out of all IA performed, maximum (45%) women had pregnancy between 10-13 weeks and rest 5%, 41%, 6% and 2% had pregnancy of around < 6 weeks,> 6-≤ 9 weeks, ≥ 10 - ≤ 17 weeks and ≥ 18-20 weeks respectively. While in Melghat region 44% women reported IA between ≥ 6- ≤ 9 weeks and 48.14% between >10-≤13week, late IA continued to be sought. Further 10-13 weeks pregnancy is also not safe because medical means may not be used and surgical procedures too have dangers. Although IA in Melghat region were much less compared to Sewagram region, all of them were reported to be performed at health facilities, maximum (62.9%) at PH. One of the significant findings was that 4% IA in Sewagram region were self-induced unsafe abortions at home. Self-managed abortion, is a model of abortion care used across a range of settings. It is essential to identify gaps in the research, and make recommendations to address such gaps⁷. Fortunately women’s health did not get affected. There were two MC in the region and one DH, SDH and PHs. It was not clear whether women opted for surgical methods or medical means or they were not given a choice for IA. In Melghat region 63% women had IA performed by medical methods and 37% by surgical procedures in Sewagram region 76% by medication and 23% surgically.

In FGDs in Sewagram region some women said that if the need be they would take advice from health personnel for IA. They had some knowledge but a lot of misconceptions. In Melghat region awareness was much less with many more misconceptions. Jha et al⁸reported that an estimated 10 million female fetuses were illegally aborted in India and around 500,000 girls were being lost through sex-selective abortions annually. Gupta⁹reported that for estimated four post-natal deaths, there was one prenatal death among girls, which suggested that about one million fetuses or unreported infanticides occurred in India between 1980 and 2010. Another study ¹⁰revealed that overall, there were 4·2 to 12·1 million sex selective abortions of girls between 1980 to 2010. However, information from many studies¹¹has indicated that unintended pregnancy, rather than sex of the child underlies demand foremost of the IA. Analysis of National Family Health Survey-2 (NFHS-2)¹²recordings of 90000 women in India revealed that between women who had all boys and those who had all girls, there was no significant difference in the probability of the raving an abortion. Only in one (Haryana) state, out of the 26 states from where information was sought, women whose previous child was a girl, were about two times (1.8) more likely to terminate the current pregnancy than other women. Saha¹³reported that Maharashtra had a higher incidence of sex-selective abortions and unwanted sex of the fetus was the reason stated by 12.5% of abortion seekers, 19% rural and 5.8% urban respondents. However in the present study which was rural community based in two sets of villages of two districts of Maharashtra, there was no evidence of sex selective abortion. As such number of women who had IA in Melghat region was low. What is happening in rural women specially those who lacked resources and /or have access problems was not well known. So present study was done which revealed that IA were used by few women, that too for spacing without use of contraception or economic reasons or vague health reasons. IA seeking for advanced pregnancy continued. PH facilities were used even by women with extreme poverty. There was no evidence of sex selective abortions. There are reports that despite the liberal abortion law that has existed in India for over three decades, access and quality of services is low in most parts of the country, especially in rural areas¹⁴. Stigma regarding abortion, general lack of knowledge about reproductive health, and limited access to abortion services often resulted in women seeking and obtaining criminal abortions¹⁵. But it was not so in the present study done in community in rural tribal women.

Utility of IA in women with low resources was low. Most had IA at health facilities but 4% at home in villages where medical colleges were near by, though no complications occurred. There were misconceptions and lack of awareness. Table 1, Table 2.

We are grateful to the Indian Council of Medical Research (ICMR), New Delhi for the financial support for doing the study. We thank the rural tribal women for the cooperation in conducting the study. Thanks are due to Dr. Naina Kumar for all the help during submission of the project, also research assistants, office staff for the information collected and help in analysis of the data and documentation.

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