Is Abortion being used as a form of contraception in India?

According to the Brihanmumbai Municipal Corporation (BMC) – a civic body that governs the city of Mumbai, that the city witnessed a 44% rise in the number of abortions in the year 2012.  While 19,701 abortions were registered in 2011, BMC data from various public and private hospitals and nursing homes in 2012 showed 28,455 abortions.[1] So, what is the reason for the sudden increase? It would be interesting if given information about abortions has been presented by age and socioeconomic status.

The health experts say that the steep increase in the number of abortions shouldn't be linked to sex-determination tests. "Most of these abortions have been carried out in the first trimester when it isn't possible to detect the sex of the fetus," said a doctor with a BMC hospital. Public health officials say it is largely due to better reporting of data by hospitals/clinics brought on by computerization. However, it appears that young women are increasingly using abortions or repeat abortions as a form of birth control.

Abortion is the termination of pregnancy by the removal or expulsion from the uterus   of a fetus or embryo prior to viability. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced. The term abortion most commonly refers to the induced abortion of a human pregnancy. It can be medical or surgical.  Abortion is legal in India. The Indian abortion laws fall under the Medical Termination of Pregnancy (MTP) Act, which was enacted by the Indian Parliament in the year 1971. The MTP Act came into effect from April 1, 1972 and was once amended in 1975. India’s abortion law is liberal. As per India’s abortion laws only qualified doctors under stipulated conditions can perform abortion on a woman in an approved clinic or hospital.[2]

If Mumbai alone has so much of abortion cases, if the whole country is taken into account the figures would be blasting. Officially there is no precise estimation on annual incidence of induced abortion. The statistics which Ministry of Health and Family Welfare (MoHFW) publishes pertains only to the reported MTP cases conducted in government's recognized hospitals/clinics. According to available official statistics, the number of abortions performed as per MTP Act has increased from 388,405 in 1980-81 to 620,472 in 2010-11. However, these figures are only the tip of an iceberg as it is estimated that in India less than ten percent of the abortions are carried out in government recognized institutions.[3]  India recoded around 6.5 million abortions in 2008 of which 66% were deemed unsafe, as per the MoHFW, Government of India.[4] It means an additional 6.0 million abortions are conducted illegally. Majority of these cases are done in rural areas having inadequate facilities and hence done in an unhygienic and unscientific way. All such abortions are considered as illegal and hence not reported in any official statistics. These illegal abortions are a major determinant of continued high levels of maternal morbidity and mortality in India. According to, the MoHFW, 8% (approximately 4,600 deaths annually) of all maternal deaths are due to unsafe abortion

Now question arises: Why Women Choose Abortion? Or what are reasons behind the abortion decision? A woman's decision to have an abortion is "motivated by multiple, diverse and interrelated reasons," as per the   Alan Guttmacher Institute.[5]  In other words, reasons why women have abortions are diverse and vary dramatically across the world. Some of the most common reasons are to postpone childbearing to a more suitable time or to focus energies and resources on existing children. Others include being unable to afford a child either in terms of the direct costs of raising a child or the loss of income while she is caring for the child, lack of support from the father, inability to afford additional children, desire to provide schooling for existing children, disruption of one's own education, relationship problems with their partner, a perception of being too young to have a child, unemployment, and not being willing to raise a child conceived as a result of rape or incest, among others. An additional factor is risk to maternal or fetal health, which was cited as the primary reason for abortion in over a third of cases in some countries and as a significant factor in only a single-digit percentage of abortions in other countries.[6] Some abortions are undergone as the result of societal pressures. These might include the preference for children of a specific sex, disapproval of single or early motherhood, stigmatization of people with disabilities, insufficient economic support for families.

The MoHFW collects information about reasons behind MTP cases at the time of abortion. Table 1, based on more than 330,000 responses, clearly indicates that “failure of contraceptive” was the main cause behind the induced abortion.  It means about half of women having abortions were using a form of contraception (traditional or modern) at the time of becoming pregnant. Inconsistent use was also part of this response including lack of access to or rejection of available contraceptive methods. More than one fourth felt that negative impact on the mother's physical and mental health was another important reason. Taken at face value, this reason may sound selfish. But a pregnancy that occurs in the wrong place at the wrong time can have a lifelong impact on a woman's ability to raise a family and earn a living. Less than half of the acceptors were illiterate and literate below primary (45%). Official statistics also indicate that more than 60% of acceptors were between 20 to 29 years of age. It means most of them were married.

 

       Table1: Distribution of MTP cases by reasons for terminations, 2003-04

Reasons	Per cent
Failure of contraceptive	46.3
Grave injury to physical and mental health	26.1
Danger to life	12.1
Substantial  risk and rape	4.9
Others	10.6
Total	100.0
Total number of MTP cases who responded	331,441
Source: Family Welfare Statistics in India - 2006, Ministry of Health and Family Welfare, GoI. New Delhi.

 

Based on the field study, the Forum for Population Action estimated that most abortions in the study areas were obtained by poor women because they have much higher rates of unintended pregnancy.[7] The following statements recoded during the study reflect concerns that play a role in influencing women to terminate their pregnancies:

·         I don't want more children or I'm done with childrearing

·         I'm not ready to become a mother or not ready for another child

·         My husband/partner/parents  wants me to have an abortion

·         There are problems with the health of fetus

·         There are problems with my own health

·         Available family planning methods are not suitable

·         Quality of family planning services is not up to the mark

·         I don't want others to know about my pregnancy 

        

What is future of abortion in India? In other words, whether number of abortions will increase?  This requires an understanding of relationships between contraception and abortion. According to Cicely Marston and John Cleland[8] that the “relationship between levels of contraceptive use and the incidence of induced abortion continues to provoke heated discussion, with some observers arguing that use of abortion decreases as contraceptive prevalence rises and others claiming that increased use of family planning methods causes abortion incidence to rise”. Based on the data from several countries, the authors concluded that: “Rising contraceptive use results in reduced abortion incidence in settings where fertility itself is constant. The parallel rise in abortion and contraception in some countries occurred because increased contraceptive use alone was unable to meet the growing need for fertility regulation in situations where fertility was falling rapidly”.

In India, looking to the present state of family planning, the contraceptive use alone will not be able to meet the growing need for fertility regulation since fertility is falling rapidly.  Many experts, therefore, feel there is a reason for the rising numbers — fewer options for women with regard to the method of abortion.  Approximately 35 million pregnancies occur each year in India. Out of this, more than two in five pregnancies are unintended by the women who experience them, and half or more of these pregnancies end in abortion including induced abortion.  It is estimated that around 26.5 million children are born in India every year and out of this about 6 million births have been classified as unplanned or unintended. Approximately two-thirds of these pregnancies resulted from non-use of contraceptives; clearly indicating the need for easy availability of quality family planning services with proper “method mix”. India's family planning program has largely failed to encourage the use of reversible methods, particularly among young women (age 15-25) who are in the most fertile years of their reproductive period.[9] In addition, around one-third of unintended pregnancies resulted from the ineffective use of contraceptives, which suggests the need for improved counseling and follow-up of couples that adopt a method. In other words, there is a tremendous need to revamp the family planning program in India to provide services looking to the needs of clients, since abortion is increasingly being used as a form of contraception.

What ever may be the case; the trend of increase in abortions each year like Mumbai is very negative and should be viewed seriously by the government and voluntary/donor organizations, before things go out of hand.

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[1] Refer: News item: Mumbai saw 44% more abortions last year, Times of India, May 20, 2013.

[2] Chandrasekhar, S. 1994.  India's Abortion Experience:  1972-1992. Denton, TX: University of North Texas Press.

[3] For details, refer: Khan M.E., Barge Sandhya and Philip George. 1996.  “Abortion in India: An Overview”, Social Change vol. 26(3 & 4).

[4] Refer: Kounteya Sinha, “Encourage women for safe abortion: NRHM”, Times of India, July, 7, 2012.

[5] Refer a note entitled: “Women and Abortions: the Reasoning behind the Decision”, circulated by the National Organization for Women (NOW), an organization of feminist activists in the United States.

[6] Bankole, Akinrinola; Singh, Susheela; Haas, Taylor. 1998. "Reasons Why Women Have Induced Abortions: Evidence from 27 Countries". International Family Planning Perspectives 24 (3): 117–127.

[7]  Devendra Kothari. 2010. Fertility preferences in Rajasthan: An analysis, FPA Working Paper, Jaipur: Forum for Population Action.

[8] Refer: Cicely Marston and John Cleland. 2003.  “Relationships between Contraception and Abortion: A Review of the Evidence, International Family Planning Perspectives, 26 (1).

[9] Refer: Author’s Blog - Controversy over Injectable contraceptives in India: How to resolve it? August 1, 2011 at link kotharionindia.blogspot.com.