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.

---

[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.

Relevance of Two-Child Norm in emerging demographic scenario of India (Part II)

Dr. Devendra Kothari

Population and Development Analyst,

Forum for Population Action

The concept Two-Child Norm (TCN) as a policy measure was introduced in some States of India through the Panchayat Raj Institutions as well as population policies in the late nineties, as noted earlier (see part I). The governments of these States insist that those with more than two living children are debarred from contesting panchayat elections or remaining in office. Now question arises whether this intervention   has been able to achieve its intended impact on the population growth.

Over the past 20 years there has been a steady decline in the annual population growth rate from 2.14% in 1991 to 1.95 in 2001 and further to 1.62% in 2011. The rate of growth has declined in all the States and Union Territories (28 States and 7 UTs) during 2001-2011 except Tamil Nadu, Chhattisgarh and tiny Pondicherry (UT), and this is a good sign. The rate of decline was slow in the Four Large North Indian States of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh as compared to other States of India.  Though the annual growth rate during 2001-2011 has registered the sharpest decline since independence, in absolute terms the population of India has increased by a whopping 181.5 million during the period. The absolute addition during the decade was slightly less than the previous decade (182.3 million). Demographic projections show that India is likely to cross China as the most populous nation before 2025.[1]

India's Total Fertility Rate (TFR) - the average number of children that would be born to a woman over her lifetime - that has remained stagnant at 2.6 since 2009 could finally see a drop in 2011, as per the Registrar General of India. However, India has seen a steady decline in TFR during the last two decades that has come down by 31% from 3.6 in 1991 to 2.5 in 2011. Among major States of India having population 25 million or more in 2011, Bihar (3.6 children per woman), Uttar Pradesh (3.4), Madhya Pradesh (3.1), Rajasthan (3.0), Jharkhand (2.9) and Chhattisgarh (2.7) have worst TFR; while Tamil Nadu (1.7), West Bengal (1.7), Andhra Pradesh (1.8),  Kerala (1.8),  Maharashtra (1.8), Punjab (1.8), and  Karnataka (1.9) have already  achieved targeted  replacement level fertility required to initiate  the process of population stabilization.  According to the National Population Policy 2000, India should have reached replacement-level fertility rate of 2.1 by 2010, and attain population stabilization at 1450 million by 2045. The stable population is a stage when the size of the population remains unchanged. It is also called the stage of zero population growth. However, India expects to reach population stabilization of 2.1 TFR at 165 crore by 2060.

As noted earlier, Andhra Pradesh, Rajasthan, Madhya Pradesh and Uttar Pradesh adopted State-specific Population Policies with a provision of TCN in late nineties but except Andhra Pradesh remaining States could not achieve the   targeted fertility goals, as shown in  Table 1 (Cols. 2 and 3).   For example, Madhya Pradesh aimed at achieving the replacement level fertility of 2.1 children per woman by 2011 but it is far away from the targeted goal – it recoded TFR of 3.1 in 2011. On the other hand, Andhra Pradesh was able to achieve the goal of   replacement fertility, as targeted.  It appears that incentives, disincentive or legal restriction on couples over the number of babies they can have (like TNC) are not going help to achieve the goal of population stabilization. What we need is the client centred service delivery system.

Table 1: Targeted Total fertility (TFR) to be achieved by 2011 as per population Policies and actual TFR in and level of unwanted fertility and unmet need for modern contraceptives.

States with  Population Policy (with year of adoption )	Targeted TFR  to be achieved by 2011 as per Population Policy*	Actual TFR in 2011**	No. of unwanted children/ woman@	% of total  births 4+@	% of unmet need for contraceptives@
1	2	3	4	5	6
Andhra Pradesh (1997)	1.5	1.8	0.3	08	05
Rajasthan (1999)	2.6	3.0	1.0	32	15
Madhya Pradesh (2000)	2.1	3.1	1.0	31	11
Uttar Pradesh (2000)	2.6	3.4	1.5	38	21
Bihar#	--	3.6	1.6	36	23
India (2000)	2.1 (2010)	2.4	0.8	25	13
Note” # Bihar does not have a state- specific population policy. Source: * Population policies, **Registrar General ,  India : @National Family Health Suvey-3

Andhra Pradesh is one such example. During the early nineties, the State government decided to revamp its reproductive healthcare delivery system looking to the needs of clients[2]. It was a political decision and this increased the use of reproductive health services significantly.[3] As per the NFHS-3,[4] more than two-thirds of married women in Andhra Pradesh used modern contraception in 2005-06, one of the highest in India. It had dramatic impact on fertility by reducing unwanted pregnancies.  Andhra Pradesh exhibits one of the lowest fertility among major States of India – 1.8 children per woman. It is interesting to note that women with no education or less than 5 years of education are more likely to use contraception than women with more education, since reproductive health services are easily available looking to the needs of clients.  As a result, only 5% of currently married women have an unmet need for family planning, down from 8% in NFHS-2 (1998-99) and 10% in NFHS-1 (1992-93). Currently, 94% of the demand for family planning is being satisfied, up from 82% in NFHS-1. The impact of client centered reproductive health care could be seen from a comparison of the birth order distribution in NFHS-1, NFHS-2, and NFHS-3 for married women. The proportions of births of order four or higher decreased from 22% in NFHS-1 to 15% in NFHS-2 and 8%t in NFHS-3. All these had an impact on the level of unwanted fertility.  Andhra Pradesh recorded one of the lowest unwanted children per woman in India (0.30, as shown in Table 2 (Col.4).   Not only in family planning but in other areas of reproductive healthcare, Andhra Pradesh has done equally well. In the State, 85% of women had at least three antenatal care visits for their last birth. 

On the other hand, total fertility in Rajasthan is the third highest among the major states of   India. The largest differentials in fertility are by economic status and education. At current fertility rates, women with no education will have twice as many children as women with 10 or more years of schooling (3.7 children per woman compared with 1.8). Among the major States of India, total unwanted fertility is the third highest in Rajasthan (one child per woman), as shown in Table 1. Despite a 15 percentage point increase in current contraceptive use among currently married women since NFHS-1, less than 45% of women in Rajasthan are currently using any modern contraceptive method. Around 15% of married women in Rajasthan have an unmet need for family planning (Col. 6), down from 18% in NFHS-2.  The distribution of births by order is yet another way to view fertility and performance of reproductive healthcare service delivery system. Around one third of total births in Rajasthan in 2005-06 were of order four or higher, which was the third highest among the major States of India. Further, no significant decline was seen in the higher order births between NFHS-2 and NFHS-3: 34% versus 32%.  Despite substantial improvement in the coverage of antenatal care for mothers, only 4 in 10 women in Rajasthan received at least three antenatal care visits for their last birth in the past five years. Full immunization coverage is lower in Rajasthan than in any other state except Uttar Pradesh, as per NFHS-3. A little more than one-quarter of children age 12-23 months are fully vaccinated against six major childhood illnesses: tuberculosis, diphtheria, pertussis, tetanus, polio, and measles.

It appears that poor performing States, containing around 50% of total population of India, are not able to provide clients centred reproductive health services.  More than 15 million currently married women in 2011, mostly in these Srares have an unmet need for family planning,[5] and that figure is increasing. Often, these women travel far from their communities to reach a government health facility, only to return home ‘empty handed’ due to shortages, stock outs, lack of choices and/or non availability of doctors and paramedical staff. When women are thus turned away, they are unable to protect themselves from unwanted/unplanned pregnancies.  More than 26 million children are born every year in India; and out of this about 6 million births have been classified as unplanned/unintended or simply unwanted. Based on findings of the National Family Health Surveys 1, 2 and 3, it is estimated that currently there are around 450 million people out of 1200 million in India who are product of unwanted pregnancies, and most of them are from the lower economic strata.[6]   

In sum, over the past three to four decades, many State governments in India have experimented with schemes like TNC including specific incentives and disincentives to lower the rate of fertility. Most such schemes have had only marginal impact and, in some cases, have been counterproductive. Thus, first priority is to provide universal access to family planning, as set out in Millennium Development Goal 5b – achieving universal access to reproductive health by 2015.  Without this, women are unable to exercise their reproductive rights.  The principle of informed choice backed by quality RH services is essential to the long-term success of the family planning programs. Any form of coercion has no part to play. Though very-very small numbers of elected representatives of local-self government including Panchayats have so far been removed under the Two-Child Norm policy,[7] but there is no need to implement such measures or to provide incentives and disincentives to achieve the goal of stable population. I, therefore, strongly urge for removal of the Two-Child Norm in our efforts to achieve population stabilization. In the changed situation most of the couples, even those belonging to the lowest economic strata, do not want more children. But, they still have them, primarily due to lack of client centered reproductive healthcare.  The real need is to provide services in un-served and underserved areas by realigning the capacity of health system to deliver quality care to suit the needs of clients, especially those belonging to the “bottom of pyramid”. Therefore, reproductive healthcare should be an essential plank in achieving population stabilization and empowering the poor. At the same time, investment in education has to be increased to improve the quality of education especially at the government schools and colleges where most of the students are from poor and rural families. It is because the pivot upon which the fate of the nation hangs in balance is education.

---

[1] Kothari, Devendra. 2011. Implications of Emerging Demographic Scenario: Based on the Provisional Results of Census of India 2011, A Brief, a publication of Management Institute of Population and Development. Parivar Seva Sanstha, New Delhi.

[2] Among many initiatives of the Government of Andhra Pradesh, the establishment of “Round the Clock Women Health Centres”   wan an important one.  470 PHCs (Primary Health Centres) in the backward areas have been designed as Round the Clock Women Health Centres in the nineties. Normal delivery services are being provided round the clock in these centres by nursing staff of PHC. 450 doctors as well as ANMs have been taken on contract in these PHCs. Specialist clinics by Gynecologist and Pediatrician are being provided in these institutions on a fixed day once in a week. Additional facilities like telephone and vehicle for transportation are also provided to improve communication and referral system for emergency cases.   For detail, see document:  Brief of the Family Welfare Department, Office of Commissioner of Family Welfare, Government of Andhra Pradesh, Hyderabad, 20.06.2003.

[3] Kothari Devendra and Sudha Tewari. 2009. Slowing Population i Growth in India: Challenges, Opportunities and the Way Forward. MIPD Policy Brief No. 2, Management Institute of Population and Development. New Delhi.

[4] IIPS.  2007.  India: National Family Health Survey, 2005-06. Mumbai:  International Institute for Population Sciences.

[5] The standard definition of unmet need depends upon the apparent inconsistency between a woman’s contraceptive behavior and her stated reproductive preferences. The concept of unmet need was highlighted first time in India in a study conducted by the author in Rajasthan in 1988-89 on behalf of Ministry of Health and Family Welfare, Government of India. For details, see Devendra Kothari, “Family Planning Programme in Rajasthan: Beyond the Existing Approach”, Indian Institute of Health Management Research, Jaipur, 1989.

[6] Ibid. Kothari Devendra. 2011.

[7] According  to  Nirmala Buch, who runs a Bhopal-based NGO,  412 panchayat members in Rajasthan, 350 in Madhya Praddssh and  275 in Haryana have already  been removed from their posts, because they failed to comply with the two-child norm. Refer: Buch, Nirmala. 2005.  Law of Two-child Norm in Panchayats: Implications, Consequences and Experiences, Economic and Political Weekly, Vol 40, (24), June 11, pp 2421-29.