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QUALITY OF ABORTION CARE: A REALITY
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From Medical, Legal And Women’s Perspective
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A study in two districts of Maharashtra
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Sunita Bandewar
(assisted by Madhuri Sumant)
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Research Centre of Anusandhan Trust
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Centre for Enquiry into Health and Allied Themes (CEHAT)
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AUGUST 2000
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Draft not to be Qouted
/ CMC
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QUALITY OF ABORTION CARE: A REALITY
From Medical, Legal And Women’s Perspective
A study in two districts of Maharashtra
Sunita Bandewar
(assisted by Madhuri Sumant)
Research Centre of Anusandhan Trust
Centre for Enquiry into Health and Allied Themes (CEHAT)
PUNE OFFICE
2/10, Swonond, Aapli Sahokari Society, 481, Parvatidarshan,
Pune - 411 009. Tel.(91) (020) 444 3225,444 7866
E-mail: cehatpun@vsnl.com
MUMBAI OFFICE
2nd Floor, C/o BMC Maternity Home, 135 A-E, Military Road,
Next to Lok Darshan, Mono I, Andheri (E), Mumbai: 400 059.
Tel.:(91) (022) 851 9420; Fax.: (022) 850 5255
E-mail: cehat@vsnl.com
August 2000
Acknowledgements
We would like to thank individually all the doctors and women who agreed to give
interviews and provided us with the required information without hesitation, which gave
useful insight to our study. We are grateful to them for the hospitality they bestowed
upon us. The study would not have been possible without their active participation and
co-operation.
Our sincere thanks to the Government officials, who gave their valuable time and
information, which was of great importance to our study. In that, Dr.Mandakini Megh,
Deputy Director of Health Services needs a special mention.
We would like to acknowledge & specially thank our consultants Dr Anant Phadke, Dr
Madhuri Talwalkar, Ravi Duggal, Padma Prakash, Dr A M Deshpande for their constant
support and invaluable inputs. We owe special thanks to Anant for his tenacious and
warm support all through the study and to Ravi for giving us valuable feedback during
the last & critical phase.
We are extremely grateful to participants of the State level consultation meeting on
Access to 'Safe and Legal Abortion': Issues and concerns’, and CMTP registration
procedure: Issues and concerns’ for enriching our understanding of the issue at hand.
We are also grateful to our team members Dr. Hemlata Pisal and Ms. Mugdha Lele for
their valuable support, especially during the phase of data collection. We are also
thankful to Ms. Anjali Ganpule and Ms. Rohini Lele for their short but meaningful and
lively association with the study. Over and above the diverse academic inputs of theirs to
the project, each one’s unique qualities gave a unique character to the team and
maintained its spirit.
We offer our very special thanks to Ms. Shelley Saha for her enthusiastic support and
cheerful help during the critical last phase of the report completion.
We also are thankful to Mr. Kiran Mandekar and Ms Sneha Fulambrikar for their
secretarial assistance. Our erratic work schedules could be maintained only because of
Kiran’s diligent and tolerant secretarial support.
We are also grateful to all our colleagues at CEHAT to support us in various capacities
towards completing this study.
We would be remiss without expressing our deep gratitude to Dr Amar Jesani and Ms
Manisha Gupte for being the source of our inspiration to take up and pursue abortion
research. Special thanks to Amar for being with us through ups and down during the
tenure of the project in addition to being the sounding board.
Finally, we would like to the Ford Foundation for its generous grant, which allowed us to
conduct this study.
We must add that although we greatly benefited from the advice, help and suggestions
received from all those mentioned above, the errors and omissions in this report are our
.own.
CONTENT
Acknowledgment
List of abbreviations
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Chapter I: Quality of abortion care: Perspectives and context
Chapter II: Study design and methodology
P54
Chapter III: Access to abortion care services: Availability, approachability and
affordability
Chapter IV: Physical standards: Infrastructure, equipment & instrument; and drugs
Chapter V: Human power: Availability, strength & professional competence
Chapter VI: Physical Standards and Human Power: A composite Analysis.
Chapter VII: The MTP Act: Knowledge and Perception of the Head of the Institution
and the Providers.
Annexures
1:
Preparatory survey schedule.
2(a): Interview schedule to be administered with the Head of the Institution
2(b): Interview schedule for provider
2(c): Information to be gathered at the centre
3(a): Integrated observation and interview guide
3(b): Observation guide
3(c): Interview/Observation guide for woman with post-abortive complications
3(d): Record sheet for screening case paper.
4:
Glossary and notes
Protocol and guidelines for research team members/investigators
5:
The MTP Act, 1971 (along with Rules and Regulations, 1975)
6:
Letter of introduction for the respondents.
7:
F
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List of Abbreviations
ACF: Abortion care facility
AN: Anaesthetist
AP: Abortion care provider
CH: Cottage hospital
FT: First trimester abortion (length of gestation upto 12 weeks)
FWC: Family welfare centres
GA: General anaesthesia
HCF: Health care facility/institution. Institution and Facility are used synonymously
HI: head of an health care institution
LA: Local anaesthesia
LT: Laboratory technician
LR: Labour room
NBM: Nil by mouth
NR-ACF: Non-registered abortion care facility
OT: Operation theatre
PHC: Primary Health Center
PPC: Post partum centres
R-ACF: Registered abortion care facility
ST: Second trimester abortion (length of gestation upto between 13 -20 weeks)
RH: Rural hospital
WB: Ward boy
UPT: Urine pregnancy test
CHAPTER I
QUALITY OF ABORTION CARE: PERSPECTIVE AND CONTEXT
1. Introduction
2. TheMTPAct
2.1. The content and the critique
2.2. Implementation of the Act
3. Status of induced abortion in India: A scenario
3.1. Incidence of induced abortion, mortality, morbidity
3.2. Abortion services and providers
4. Concerns for quality of care
4.1. An historical background
4.2. Different contexts of family planning and abortion care services in India
5. Aims and objectives of the study
6. Quality of abortion care: A model
6.1. Structure
6.2. Process
6.3. Outcome
7. The salient features of the study
1. INTRODUCTION
Literature, empirical research, people’s experiences as regards abortion practices all
over the world, especially in the latter half of the present century indicate that access to
abortion services depends much on state’s political agenda. In that case the State will
do so irrespective of whether there existed such a legislation or not. For example, in
Bangladesh, a very restrictive abortion law is softened by improving access to
abortion services through government funded Menstrual Regulation (MR) services.
The law prohibits abortion except to save the life of the mother. But to enhance the
family planning programme to meet state’s goal to limit population growth it began to
support MR services. By leaving MR practices outside the purview of definition of
abortion, women are allowed to manage unwanted pregnancies in a rather ‘open
secret’ fashion. The State could meet its ends without getting into controversy by
liberalising the existing abortion law. In Hungary, ‘social justifications’ are interpreted
to accommodate virtually all women wanting to have abortions. On the other hand in
Bermuda, Kuwait and Quatar the more liberal laws compared to earlier ones make
little sense for women who face insurmountable administrative obstacles in getting
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Introduction
1
abortion services. We also find intra-country variation as regards this. Many more
examples could be quoted. The state’s encouragement for abortion or reluctance to
offer abortion services is primarily to meet its own ends, viz. to control population
growth (in Bangladesh) or to pacify fundamentalists (in Bermuda, Kuwait, Quatar).
The racist motivation of some governments (viz.: pronatalists policies towards whites
and antinatalist towards blacks in the US) is more than obvious. This, therefore,
indicates that abortion legislation (or lack of it) is less to do with actual availability of
abortion services1. This is not to deny the significance of legislative measures as one
of the essentials in moving towards making possible women’s access to safe and legal
abortion care services. In this light legislative measures are essential but not sufficient.
Policies and legislative measures, either liberal or restrictive in nature, decriminalising
abortion started taking shape the world over since middle of the 19th century. The
context of decrimilalising abortion differed from nation to nation. More often than not
liberalisation of abortion policies had links, as explained above, with state’s agenda and
its pro or anti-natalist population policies. This influenced not only the content and
nature of legislation but also quality and nature of abortion care service delivery.
In India it is more than a quarter century since the Medical Termination of Pregnancy
(MTP) Act is passed in 1971 and implemented in 1972. It decriminalised abortion.
However, there are reasons to believe that the manner in which the Act is being
implemented is less adequate and the quality of care that is available to women seeking
abortion care either at institutions or otherwise are gruesome. Among others, the wide
gap between the estimates of incidence of abortion and the reported MTPs as per the
official records testifies this. Primarily the objective of this study was to assess
quality of facility based abortion care services holistically.
The present chapter presents the content of the MTP Act in brief. It offers a critique
of the legislation which has provided the analytical framework for this study.
Further it provides a scenario analysis as regards abortion care services,
incidence of MTPs and estimates of incidence of induced abortions, mortality
and morbidity situating the need to study quality of abortion care services.
Thereafter it details aims and objectives of the study and presents the quality of
abortion care model that has been evolved to assess the quality of abortion care during
this study.
2. T1IEMTP ACT
2.1 The content and the critique
Liberalisation of abortion through implementation of the MTP Act took place without
it ever being on the agenda of women’s movement. The Act is often described as one
of those revolutionary efforts for two reasons. One, it was for the first time in the
world that abortion was made legally permissible in case of failure of contraception.
And two, it did not require husband’s consent for a woman to undergo abortion.
1 The agrument placed here is drawn from Jodi L Jocobson’s article titled Global Politics of Abortion, a
Wordwatch paper. Please see the Reference list
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Introduction
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Despite these strengths of the z\ct, it provides space to be critiqued for its overmedicalisation and for allowing its liberal or restrictive interpretations depending upon
the broader socio-political context.
The Act stipulates that pregnancies could be terminated legally only under certain
circumstances and for certain reasons by only a registered Medical Practitioner with
the necessary qualifications and training and at a place where the facilities available are
in keeping with the standards prescribed in the Rules and Regulations of the Act. In
the following it details specifics of the Act and our critique.
Legally permissible indications for terminating pregnancy and length of
gestation: It is stated in the Act that a pregnancy may be terminated
(a) where the length of the pregnacy does not exceed twelve weeks if medical
practitioner is, or
(b) where the length of pregnancy exceeds twelve weeks but does not exceed twenty
weeks, if not less than two registered medical practioners are, of opinion, formed
in goodfaith, that(i)
(H)
the continuation of the pregnancy would involve risk to the life of the
pregnant woman or ofgrave injury to her physical or mental health; or
there is a substantial risk that if the child were born, it would suffer from
such physical or mental abnormalities as to be seriously handicapped.
Explanation 1: Where any pregnancy is alleged by the pregnant woman to have been
caused by rape, the anguish caused by such pregnancy shall be presumed to
constitute a grave injury to the mental health of the pregnant woman.
Explanation 2: Where any pregnancy occurs as a result offailure of any device or
method used by any married woman or her husband for the purpose of limiting the
number of children, the angusih caused by such unwanted pregnancy may be
presumed to constitute a grave injury to the mental health of the pregnant woman.
The critique:
Medical practitioners as 'gatekeepers ’
The Act enjoins the medical practitioner as an ultimate authority to assess any possible
consequences to women’s mental and physical health of continuing the pregnancy to
full terms while deciding upon whether to provide or deny abortion care services to a
woman. In that sense a medical practitioner plays a role of‘gatekeeper’ in the process
allowing over-medicalisation of abortion care services.
Patriarchal and gender biases in assessment of women’s abortion needs
An assessment of women’s abortion needs reflected in the ‘explanations’ rendered in
the Act inherit patriarchal and gender biases. It exhibits moralistic positions about
women’s sexuality. It links woman’s sexuality and use of contraception with her
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Introduction
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marital status. Simultaneously, this then precludes all other situations and
circumstances in which a woman may express her sexuality leading to a pregnancy,
may be an unwanted or unintended one.
With such formulation of the clauses and/or explanations in the Act, the pregnant
woman seeking abortion is compelled to furnish explanations that fit into the
conditions listed in the Act. It also, keeps the Act open to differing interpretations,
especially on part of the medical providers engaged in abortion care services.
Following the government’s preoccupation with population control and the somewhat
dubious motivations of the medical profession the present interpretation of the law,
ironically, has been a liberal one. However, the grave possibility of the Act assuming a
restrictive meaning without even one word of the text being altered, remains. (Jesani
and Iyer, 1993).
Implications for quality of abortion care
The current socio-political context, which permits a liberal interpretation of the Act
may allow all women to undergo an abortion when sought at the health care
institution. However, it remains to see as to how the patriarchal biases, unwritten
proscriptions about woman’s sexuality, moralistic views about the act of abortion
reflected in the formulation of the Act impact at the pragmatic level the quality of
abortion care services that a woman receives. It also remains to examine as to how the
dubious motivations of the medical professionals intersect with their efforts to fit a
particular case into the legally permissible abortion indications and what implications either positive or negative - it would have for a woman, especially in terms of quality
of abortion care she receives.
For example, research in the past has documented that husband’s consent is demanded
despite it being-illegal. ( Gupte et. al. 1999; Khan et. al., 1998).' It, therefore, needs to
be studied as to what pushes the medical fraternity to do so and what it means to a
woman and quality of abortion care she receives.
The minimum physical standards set by the MTP Act: The Act has laid down the
minimum physical standards to be maintained at a medical setup to be in position to
offer MTP services. The Act states that no place shall be approved under clause (b)
of section 4, — Approval of the Place.
i. unless the Government is satisfied that termination of pregnancies may be done
therein under safe and hygienic conditions; and
ii. unless the folio-wingfacilities are provided therein, namely:
a) an operation table and instruments for performing abdominal or
gynaecological surgery;
b) anaesthetic equipment, resuscitation equipment and sterilisation
equipment;
c) drugs and parenteralfluids for emergency use.
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Introduction
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•r-t
The critique:
Lack of clarity
There is lack of clarity which leaves a lot of scope for subjective interpretations. For
example, the terms 'safe’ and 'hygienic’ used in clause ‘(i)’ are neither defined nor
there are any guidelines to that effect in the Act. As a result, individual inspectors may
apply their own interpretations while inspecting a particular place for provision of
MTP facility. Besides, taking an advantage of this obscure formulation, the illfunctioning bureaucracy and poor implementation of any legislation in general may
allow mal-practices in the process of approval of the place.
Lack of specificity
The clause about the requirement of instruments for abdominal/ gynaecological surgery
doesn’t take into account the need to have range of various sizes of different
instruments that constitute this set. It also does not state the minimum number of sets
that must be maintained at the institution depending upon the number of clients that
may be admitted/attended at a time (size of the set up in terms of abortion admission
capacity) etc.
Assumptions about the other minimum physical standards
In general, the abortion care facilities are rarely ‘stand-alone’ type of services. They are
situated either in the general health care service facilities or in the maternity care
centres. The MTP Act lays down standards, which are primarily about instruments and
equipment required for abortion procedure and for administering anaesthesia; about the
maintenance of the hygienic and sterile conditions in the operation theatre, about
essential drugs and parenteral fluids. These are very specific to abortion care services
and do not cover the entire range of specifications as regards minimum physical
standards at the health care facilities at which abortion care services are situated.
Neither does it specify the minimum physical standards in a comprehensive manner for
a health care facility engaged in providing abortion care alone, though ‘stand-alone’
abortion care facility is not a norm.
It appears that the MTP Act assumes that the other minimum physical standards at a
particular HCF are maintained at which abortion care services are situated. However,
the situation is not so. The only medical legislation which deal with these aspects are
Bombay Nursing Home Act, 1949 which covers only urban area of the state of
Maharashtra (?); some other legislations which are applicable provincially, such as
Tamil Nadu Private Clinical Establishments Regulation Act, 1997. In absence of any
monitoring system and any vigilance mechanism in place these legislations in reality
mean little as reported by the research studies. Besides, these legislations are
applicable only regionally and not nationally. If so, the basic assumptions that seems to
have been made in the Ml P Act about health care facilities meeting the entire range of
minimum physical standards appears to be grossly unfounded.
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Introduction
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Thus, lack of any nationwide medical legislation to have such a regulatory mechanism
in place leaves much at the hands of those running the health care facilities. As a
result, practically speaking a health care facility engaged in abortion services may meet
the minimum physical standards laid down in the MTP act but may violate some others
impacting negatively on quality of abortion care.
Against this backdrop, it is essential to lay down a comprehensive model of quality of
abortion care against which an assessment to be made.
Experience or training/qualification of the abortion service providers: The Act
states that a medical practitioner registered in the State Medical Registered
0)
(H)
(Hi)
(iv)
if has completed six months of house surgency in gynaecology and obstertics;
or
if he had expereince at any hospital for a period of not less one year in the
practice of obstetrics and gynaecology; or
if he has assisted a registered medical practitioner in the performance of
twenty five cases of medical termination ofpregnancy in a hospital established
maintained. or a training institute approved for this purpose, by the
or maintained,
Government; or
if holds a post-graduate degree or diploma in gynaecology and obstetrics, the
experience or training gained during the course of such degree or diploma.
The critique:
Non-comparability among the stipulated alternatives as regards experience/training
of the aboriton service providers
The clause ‘(iii)’ suffers from lack of clarity. The term ‘assisted’ is ambiguious. It
could be interpreted as no hands-on practice is required but only ‘assistance’
experience is sufficient. If so, the wide gap can be observed, between ‘(iii)’ and the rest
of the clauses and thus these aforesaid experience/training requirements are not
comparable or at par with each other. .
While it mentions the need of experience of assisting 25 cases, it fails to make any
reference to the need of experience to handle a range of variations that exist with
regard to abortion situation. One, while acknowledges the problems of feasibility of
having such stricter rules, feels the need to incorporate, at least, a theoretical
component in the training module.
Exclusive emphasis on medical skills ignoring non-medical ones
The stipulated ‘experience and training’ requirements to be met by the abortion service
providers component exclusively focuses on the medical skills. The non-medical
aspects, such as, provider-client interactions, staff-client interactions, quality of
information exchange including counselling that is required during the delivery of
abortion care services, do not feature here at all. These soft facets of service delivery
have a special significance in abortion care services. Given the complexities around
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Introduction
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abortion having such skills is essential for any abortion sendee provider to be in
position to interact with her/his clients more sensitively and humanely. It plays an
important role in meeting some of the immediate reproductive health care needs of
women. These, then would have positive implications for her health in the long term.
For example, it is essential to understand her fertility history and intentions so as to
guide her appropriately about the contraception methods. This would help her to avoid
situations of repeat abortions, which certainly has negative consequences for her
health.
MTP training facilities
The Act also does not lay down any mechanism for those who aspire to learn MTP
procedures. The role of the private registered abortion care facilities remains unclear.
2.2 Implementation of the Act
Any legislation without having an arm of a clearly laid down implementation
mechanism makes it a little sense to those for whom it is meant. The MTP Act lays
down in details the reporting mechanism for heads of the abortion care facilities to be
followed. But it does not delineate the responsibility to be shouldered by the concerned
offices/government authority as regards periodic inspection of those institutions which
are registered or about having a vigilance committee to keep a track of indulgence, if
any, of institutions in illegal abortion care service provision.
Lack of such an arm would automatically lead to growth of illegal abortion service
care provision through health care institutions exposing women to unregulated and
possibly unsafe abortion care services.
With these critical comments on various aspects of the Act, we don’t intend to suggest
stricter formulation of the Act, which may negatively affect women’s access to safe,
legal and affordable abortion care services. But we certainly are concerned about the
patriarchal bias, the lack of clarity in the formulation, space for its liberal or restrictive
interpretation, its over-medicalisation etc. This is because it mostly would work against
women’s interests seeking abortion care services. In such a situation, women may
rarely be denied an abortion care but perhaps will have no control over the quality of
abortion care that she receives.
One cannot dispute the need to make available properly trained medical personnel and
well - equipped centers. Unfortunately, the ground realities are quite different in India
where basic health care services - leave alone abortion services - are inaccessible and
unavailable for many. Legal restrictions to abortions must, therefore, be coupled with
the necessary provision of services. The MTP Act fails to make the right to have
access to abortion services a justiciable right. In any case, no law can automatically
create easy access and utilisation of the abortion services, nor can it automatically
improve the quality of services. A brief analysis that follows of the current situation as
regards abortion care services, abortion related mortality & morbidity would help us
understand better the ground realities and limitations of the MTP Act at the
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Introduction
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operational level as regards its role in enhancing women’s access to safe, legal and
affordable abortion care services.
3. INDUCED ABORTION IN INDIA: A SCENARIO
3.1 Abortion care services and providers
The data on abortion services and providers need to be examined from the point of
view of its adequacy, accessibility, equitable distribution, and contribution of the public
and private health care service sector. These facets of abortion care services have
implications for women’s access to safe, affordable and legal abortion care services.
Difficulties in getting accurate data on health care services, even from the government
sources, are well documented (Nandraj, -—). In case of data on abortion services the
additional difficulties are those arising from unavailability of data on illegal institutional
and non-institutional abortion care services. The government sources provide data only
about legal abortion care services and only on certain limited aspects, such as, number
of registered MTP facilities, number of MTPs conducted, length of gestation, reasons
for abortion and method of contraception adopted post MTP, if any. The little data
that are available on illegal institutional and non-institutional abortion services come
mostly from community based or facility based empirical research.
The available data on these various aspects obtained from various sources are
presented below to highlight the fact that the present MTP services are inadequate and,
unequally distributed. The data on illegal abortion services provides us an idea of the
magnitude of the problem.
MTP services and providers
The trends in growth of the MTP facilities and their performance pattern over the years
must tell us adequately about availability of MTP services. Table 1.1 presents that
increase in number of MTP institutions is about five fold since 1972 to 1997, but the
increase in number of MTPs at these institutions is not even even two fold. It is only
about 1.4 fold. The average number of MTPs per institutions reduced to less than half
since 1972 to 1997. The average annual percentage increase in MTP institutions
between 1972-1980-1981 is 9.4, over 1981-82 to 1985-86 is 10.98; over 1986-87 to
1990-91 is 4.4 and in the last next six years till 1996-97 is 4.5. The corresponding
numbers for average annual percentage increase in MTPs is 7.8, 8.66, -0.08 and -1.2.
This indicates the regressive trends in registration of health care facilities for MTP
services and their performance. Additionally, the regressive trends in the latter reflect
on the poor performance of the institutions and the authority in informing and
influencing population about such legal abortion care facilities that women can seek
MTP services from. It perhaps is even suggestive of poor reporting and/or poor
implementation of the legislation. Moreover, there are certain spurts both, in average
annual percentage increase in number of registered institutions and number of MTPs,
which are without any correspondence between them in those respective years. This
provides us further space to doubt the ‘reporting’ and the possibiliry of other aforesaid
problems.
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Introduction
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The available data also suggest that the MTP services to date are inadequate. There
were over 22,010 PHCs; 2,662 Community Health Centres (CHCs), 13, 692 hospitals
in India in 1997 (MOH&FW, Annual Report, 1997) all of which are eligible under the
MTP Act to offer MTP facilities. Of these, only 8,891, that is 23.2 per cent, were
approved MTP institutions in the entire country in 1996-97. These institutions
conduct, on an average, 61 legal induced abortions every year. If these institutions
were to conduct all the estimated induced abortions, that is 4.7 million, in the country,
they would be required to do on an average 529 abortions every year, resulting into
nine fold increase in their work. Since these are averages, the increase in the workload
would be unevenly distributed. Needless to add, such a nine fold increase in work
would seriously compromise the quality of care unless something is done to increase
the number of registered institutions.
These scanty services are distributed unequally within the states; over private and
public health service sector; and over rural and urban areas. This would further
aggravate the problem of not having access to safe, legal and affordable abortion care
services. Table 1.2 reveals the unequal distribution over the states. According to
unpublished data for the state of Maharashtra, 1992-93, about 70.3 per cent of the
approved centres are in the private sector (Jesani and Iyer, 1995). The following
analysis of public health care facilities should give us adequate idea about the unequal
rural/urban distribution of MTP services given the fact that there prevails a trend of the
growing concentration of private health care facilities in urban areas over the decades
In general, the contribution of the public health care facilities in MTP services is poor.
The Indian Council of Medical Research (ICMR, 1991) study evaluating the quality of
family welfare services at the PHC level in 1987-89 reveals an abysmal state of affair of
rural health care services. The study covered 398 PHCs from 199 districts in 18 states
and one union territory. One of the major findings was that the majority of PHCs was
lacking in functional equipment and/or trained humanpower to carry out pregnacy
termination even after two decades of the MTP Act. Also, about 40 per cent PHCs did
not have any stock of oxygen readily available and there was a total absence of records
in one-third of PHCs. In 1994, only 8% (1800 of 21,563) of the public health facilities
both, CHCs and PHCs, qualified as ‘approved’ (Chhabra & Nuna, 1994). Often the
public health care facilities are ill-equipped as regards qualified professionals and
infrastructural facilities. For instance, all community health centres are expected to
have a surgeon, physician, an obstetrician & gynaecologist and a paediatrician. In
1995, of 2401 CHCs, only 710 ( 29.6%) were equipped with surgeon, 574 (24%) with
physician, 548 (22.8%) with obstetrician & gynaecologist and 498 (20.7%) with
paediatrician. At 7,607 (34.9%) PHCs of the total 21,802 there was no doctor.
In another multi-state study conducted by Centre for Operations Research and
Training (CORT, 1998), it was revealed that around one-quarter of PHCs in Uttar
Pradesh (UP) and Maharashtra provide abortion services. In Gujrat and and Tamil
Nadu (TN) it is one-thrid and two-thirds respectively. And among CHCs, about 59
per cent in UP, 78 per cent in Gujrat, 89 per cent in Maharashtra and 95 per cent
(CHCs and sub-district hospitals together) in TN provide abortion care services.
It is to be noted that according to the Seventh Five Year Plan (1985-90) the
Government of India stated the intention to equip all PHCs to conduct abortion
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Introduction
9
services. The data discussed above though exhibit a trend of improvement, there
remains much to be achieved.
Illegal abortion services and providers
Illegal abortion services could be both, non-institutional and institutional. The noninstitutional illegal abortion services mostly mean paramedics involved in abortion care
services and local abortionist. Institutions if provide abortion services without
acquiring legal registration be treated as illegal abortion services. Non-qualified
aboriton service providers at registered MTP centre also mean illegal institutional
abortion services. There is not much data available on this aspect. However, the study
conducted by CORT (1998) of the public health care facilities to assess quality of
abortion care services notes that all the doctors who were conducting MTP services
were not necessarily trained in the procedure. On the other hand, there were some
doctors who were trained for conducting MTP but were unable to provide the services
because the clinic did not have the required facilities. Of the total 319 Medical Officers
interviewed from four states, 205 (64%) were conducting MTPs. Of these 31 (15 %)
were not trained to conduct MTPs. The ICMR (1989) study on illegal abortion in
rural areas in two states, Rajasthan and Tamil Nadu records 422 abortions done by
paramedics, 1470 by indigenous providers, such as dais and magicians/witch/ojha and
others, and 132 by practitioners of Indian Systems of Medicine (ISM).
Survey data from 1984 showed that only about 1,000 out of total of 15,000 physicians
(that is only 6.7 per cent) trained to perform abortions were living in rural areas,
although 78 percent of the country’s population falls in this category (Jacobson, 1990).
These are glimpses of practice of illegal abortion care services. However, the wide gap
between the number of MTPs (aboriton conducted at registered MTP centres) and the
estimated number of abortions helps us to appreciate the extent of the ubiquity of such
illegal services (Table 1.4).
Inadequate financial outlays
The government funds allocated for abortions are grossly inadequate. In 1986-87, the
Ministry of Health and Family Welfare (MOHFW) formulated a central scheme for the
expansion of MTP facilities by providing Government of India funds on a year-to-year
basis. This has allotted RS 1/- per MTP performed and total expenditure of Rs. 100/per trainee doctor to a maximum of 20 trainees per training centre a year. In 1993, Rs
15/- were given towards drugs and dressing per MTP case (Chhabra & Nuna, 1994).
There is not much systematic empirical research available to know the resource
constraints and the problems being faced by the concerned authority and the abortion
service providers even in public health care services in providing quality abortion care
services. (Policy analysis and programmatic evaluation of the health financing?). A
study conducted in Uttar Pradesh documents difficulties in the programme as regards
provision of funds for instruments and maintenance and repair of the apparatus
(Mukhaiji, undated). The resource constraint could be imagined based on low health
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10
budget in general and status of affairs with regard to many other government
programmes.
Abortion services: A cause of concern
The statistics about various aspects of MTP services in India, such as, number of MTP
centres available; their distribution over public/private sector and over rural/ urban
areas; MTP training facilities and quantum of public funds allocated for the purpose,
are quite alarming. In general inadequate, difficult to access, inequitably distributed
public & private health care service over rural & urban areas, are the issues of
concerns as regards abortion care services.
The questions those need to be explored at the level of service provision are many.
What are the reasons for inadequate growth and a shift towards a regressive trend in
its growth to date of the MTP care facilities? Why is the performance of these existing
facilities poor? Is the Act being implemented effectively? If not, what is causing an
ineffective implementation? What kind of resource constraints - financial, human
power, information dissemination, redressal etc. - the process of implementation is
facing? What are the specific problems being faced by the concerned authority/offices
at various level in the process of implementation and by the medical fraternity in
getting their centres registered? Are there any mechanisms in place which ensures that
the registered centres comply with the MTP Act and have a vigilance over the
indulgence of the non-registered centres in abortion care provision? An exploration
along these lines would help us understand the issue partially. Most of these issues
must have a bearing on the quality of abortion care services that are offered to
women.
Needless to mention that service providers’ 'are the important players in providing
quality of abortion care services. The kind of perspective they hold has implications for
the quality of care that women receive. There is not much research available on
providers’ knowledge about the legislation and their views about the various aspects of
the legislative provisions that are available today and providers’ perspective on and
attitude towards women’s abortion care needs. In brief research on providers'
perspective on abortion service provision is lacking.
3.2 Incidence of induced abortion, mortality and morbidity
Data on abortion incidence are difficult to come by because, as mentioned earlier, of
the unavailability of data on incidence of non-institutional abortions. Needless to
mention that underreporting of the institutional abortions adds to the problem. We
even today have to rely on estimates, when required.
Induced abortion incidence
The Shah Committee, which was appointed to study the abortion situation in India way
back in 1966. (GOI, 1966), assumed that for every 73 live births 25 abortions take
place of which 15, that is three fifths are induced. Table 1.3 presents estimated
abortions and other related statistics. With extrapolated figures about population and
birth rate, in 1997, the estimated number of induced abortions were 4.8 million. The
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total abortion (spontaneous and induced together) rate per 1000 live births is 341 (205
induced and 136 spontaneous). Of 4.8 million induced abortions, if 0.54 were legal as
per the government data (Table 1.1), then for every single legal induced abortion there
must be 8 illegal abortions taking place. Table 1.4 shows that over the years the ratio
of legal to illegal continues to remain the same. Only about 9 per cent of the total
induced abortions seem to be legal. The rest are illegal, institutional or noninstitutional.
The community based research to study abortion incidence pattern alone are almost
absent. However, studies with focus on maternal mortality, pregnancy and related
issues may record abortion incidence and mortality etc. World Health Organisation
(1994) compiled about 17 community based studies, which made reference to abortion
incidence and mortality of unsafe abortion. These studies were conducted between
1969 to 1992 either in urban slums, rural areas or cities. Except one all were
prospective. Women constituted the study units. The abortions recorded were induced
and presumed to be non-legal or “back-street” abortions. These studies recorded
abortion incidence ranging from 0.5 to 19.6 per cent of live births. National Family
Health Survey (1992-93) records 1 per cent abortions of recent pregnancies for India
and is said to be a gross under-reporting of abortion incidence (Jeejibhoy, 1999). A
community based study conducted in 1998 in Marathwada region of Maharashtra,
records 33.4 abortions per 1000 live births. (IHMP, unpublished). The only abortion
rate study that we came across recorded induced abortion rate of 148 per one
thousand live births which is much less than 255 that could be calculated for the same
period as per Shah Committee formula (Ganatra et. al., unpublished).
The determinants/parameters for arriving at abortion incidence at a given point of time
are population and birth rate. Based on the data available then, that is about 35 years
ago, the Shah Committee assumed that there prevails about one third of wastage of
pregnancies. The major constraint, to date, seems to be not being able to adjust the
estimates in the light of the changing scenario, such as, changing trends in indications/
reasons for abortion. According to one estimate, about 10 per cent of the induced
abortions are followed after the sex selection tests (VHAI, 1999). In another rural
community based study conducted during 1994-96 in Maharasthra, it is estimated that
one in every six pregnancy terminations among married women were sex-seletive
(Ganatra et al; 1998). The same study records that women not currently married
constitute a special group of abortion seekers who have different needs and behave
differently from married women. Studies have demonstrated the large scale unmet
needs of contraception which may lead to increase in abortion for reasons of limiting
family size. A multicentric hospital based study shows that 67 per cent of abortions
were sought for limiting the family size and 44 per cent mentioned failure of
contraception as a reason to undergo abortion (Khan et. al. 1990). In this changing
context of abortion it is very likely that the figures arrived at using Shah Committee
assumption are the under estimates.
The wide gap prevails the abortion incidence based on estimates and the community
based research experiences. (Table 1.5). The wide variation even within the community
based research indicate that there must be multiple factors responsible, such as,
methodologies, socio-cultural characteristics of the communities. Abortion not being
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the focus of these studies must partially, explain the gross under reporting. It also
marks the difficulties in capturing anything close-to-actual incidence of abortion
through such community-based research. Despite these gaps and variation, the fact
that comes in forefront is that the magnitude of women’s abortion needs is substantial
enough to be ignored.
Abortion related mortality and morbidity
Globally, it is estimated that there are about 100, 000 deaths resulting from
complications. It is estimated that abortion related mortality explains about 20 per cent
of total maternal mortality. It is said that for every death due to abortion, there are
240-330 women who suffer from ill-health associated with complications of abortion.
This amounts to a disease burden of of 17-23 million morbidities worldwide (Finger,
1994). In Indian context, there exists limited data on abortion mortality and morbidity.
The share of abortion related mortality in the maternal mortality for rural India over
the period starting from 1978 to 1995 as per the official records. It shows a mixed
trend. (Table 1.6). The current pattern is characterised by a substantial rise in it
compared to that in 1978. Some other data on abortion mortality is presented in Table
1.7. The records at DHS, Mumbai at the MTP cell for three consecutive years (199697, 1997-98, 1998-99) to one’s surprise show ‘nil’ abortion related deaths and has
been the case even in the past. The ‘under (no)-reporting’ is more than obvious.
The fact that about 90 per cent of the induced abortions are estimated to be taking
place at other than registered institutions does give us the idea of the enormity of the
problem at hand of abortion related mortality and morbidity. Besides, its magnitude
could be appreciated based on the prevailing status of abortion care services in
particular and general health care services in general and the other related factors.
These include limited number of abortions that take place at institutions which are not
necessarily safe, limited number of qualified abortion service providers, its skewed
distribution over urban and rural areas, and an indulgence of untrained persons in
providing abortion care. In a PHC based study wherein 372 abortion among 300
females were studied who had undergone abortions one or more time, all the abortion
performed by quacks and paramedical had led to post-abortion complications (Mondal,
1991). And in the same study, out of the total cases aborted by MBBS private
practitioners 45.8 per cent had led to complications. Reasons for these were improper
aseptic techniques, lack of training, overconfidence and popularity in the area ignoring
meticulous care.
It is to be noted that legal abortion centres may not necessarily be providing ‘safe’
abortion care and vice-a-versa. The high percentage of abortion morbidity and
mortality must largely be attributed to lack of adequate and well placed registered
abortion care service centres. At the same, large proportion of private sector in
abortion practice contributes to abortion morbidity and mortality necessarily because it
is highly unregulated in general. In a rural community based study in Maharashtra, it
was found that abortions mostly take place within the private sector; about two-thirds
of the women complaining of a problem that was severe enough to disrupt their routine
work; and post abortion care was lacking (Ganatra, et. al., 1998).
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These data about abortion service facilities, public funds for MTP services and high
incidence rate of illegal abortions are more than telling. The serious difficulties that
arise and get compounded further are then on account of economic, socio-cultural and
socio-political factors those surround the issue of abortion.
Reasonsfor women resorting to illegal abortion care
The key question that arises is why do women resort to illegal abortion care services.
The nature of legal abortion care services on the one hand and the socio-cultural
context of woman’s abortion need on the other hand, are the two key domains that
influence women’s choice of provider. The data presented in the earlier part of this
chapter adequately reflect the possible reasons those could be attributed to the nature
of abortion care services for women seeking illegal abortion care services.
The socio-cultural factors in shaping 'abortion seeking behaviour" of women and
non-medical indicators of quality of care.
Researches have demonstrated that the socio-economic variables do impact women’s
health seeking behaviour (ref....). If so, these socio-economic and additionally the
cultural correlates of health seeking behaviour must play a much stricter role when it
comes to women’s abortion seeking behaviour. There is some evidence available to
this effect through the empirical research conducted in the second half of the 90s.
Women’s concerns and priorities while seeking abortion care were found to be
different than those in other health seeking situations (Gupte et al 1999). This study
demonstrated that among others, women’s expectations from the health care
services/providers as regards quality of care are important determinants of choice of
abortion care services/providers. Women had something to say very clearly and
precisely about ‘quality of abortion care’. It was, to an extent, different from what they
perceived to be the ‘quality of general health care or maternal health care’. While
overwhelming importance was given to ‘confidentiality^/quick service and return’ and
{.n°t wanting to make husband’s signature compulsory’ as part of abortion care. In
general, women appear willing to trade safety and quality of care considerations for
assured confidentiality, which helps explain why the private sector is preferred source
for this service. Some other researchers too have documented similar indicators of
‘quality of abortion care’. (Ganatra et al, 1998;). Reasons for approaching quacks were
documented to be secrecy, availability, affordability and accessibility of the abortion
services (Mondal, 1991). In addition to demonstrating the role the socio-cultural
factors play in shaping women’s abortion seeking behaviour, it also reflects women’s
concerns for the ‘non-medical’ aspects of quality of abortion services. Some of these
social analyses to understand ‘pathways of abortion seeking’ suggest that the prevalent
services lack users’ perspective forcing them to approach unsafe abortion care
services. A need to look beyond the physical standards of care and to incorporate
factors related to patient satisfaction in the legal provision is obvious.
Researches have also documented unawareness of women about the availability of
legal provisions for abortion services and its details (Gupte et. al., 1999; Ganatra et.
al., 1998). The complexities surrounding abortion on the one hand and lack of
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awareness of legal provision on the other appears to underlie the higher incidents of
illegal abortions which may, therefore, be exploitative, unsafe and life threatening.
Efforts towards provision of safe abortion care services, therefore, can be one of the
important health care intervention to reduce mortality and morbidity in women during
abortion. The need for safe abortion care is as important as prenatal or maternal
care given its contribution to the maternal mortality and morbidity.
Where does this scenario analysis take us? What does it tell us about the status of
induced abortion in India today? The scenario analysis provides adequate space to
critically examine the current state of affair at two levels. One is at the level of service
provision. Two is at the level of women as users of these services. The overarching
issue that emerges from the above discussion is that the magnitude of the unsafe
abortion even today continues to be worrisome to the extent that it requires to be
treated as a ‘public health concern’. If so, the situation demands an assessment of
quality of abortion care so as to delineate user sensitive health care interventions. This
is the broader context in which the present study has been undertaken.
4. AIMS AND OBJECTIVES OF THE STUDY
The overall aim of the research was to study quality of abortion care services at the
hgalth care facilities. The specific objectives were as follows:
1. To define indicators of and prepare criteria for medical and non-medical aspects of
quality of abortion care services.
2. To assess quality of abortion services at the registered and non-registered;
government and private institutions providing induced abortion services in rural
and urban Maharashtra using the conceptual framework with three components,
that is, structure, process, outcome.
3. To study as to how limitations of the MTP Act are manifested in abortion services
by understanding
(a) providers’ need and rationale for demanding husband’s signature,
(b) various coping mechanisms adopted by providers in an attempt to fit an
abortion case within the framework of the MTP Act and the institution of
the marriage and family,
(c) compromises made about quality of abortion services by both providers and
clients in case of perceived socially Cnon-sanctioned’ pregnancies.
4. To study views/reasons of providers for not adhering to the minimum ‘quality of
abortion care services’.
5. To formulate detailed and specific guidelines for improving quality of abortion care
services.
At this juncture it would be worth taking a look at the progression of the concerns in
the past for quality of health care services. The model that has been evolved for
assessing quality of abortion care in the present is evolved from these core ideas that
are discussed in the following.
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5. CONCERNS FOR QUALITY OF CARE
5.1 An historical background
Those engaged in research on quality of care are well acquainted with the trajectory it
has followed. The core ideas are believed to be borrowed from management and
industrial sectors of Japan in the 1950s and were subsequently adapted to the private
sector in the United States, including health care (Brown et al, 1995). However, one
finds that the core idea of quality of care was articulated by Ernest Codman way back
in 1910, specifically in the context of health care (Donabedian, 1989). Though the
terms ‘structure’, ‘process’ and ‘outcome’ were not used by Codman, he certainly
had conceptualised and used them in his life time practice. Various soft facets of
quality of care, now constituting ‘process’ component, were taken note of by him. For
him, the idea of‘end result’ was the vital link between the science of medicine and the
science of management. He, all through his career, pursued the idea of ‘end result’
which he believed was ‘the satisfied and relieved patient’. It was Avedis Donabdian
who put forward the structure-process-outcome model of quality of care
(Donabedian, 1988). Donabedian’s contribution to the assessment of health care is his
emphasis no^pnly on the technical domain, but also the interpersonal. He noted that
the relationship between patient and provider should be characterised by “privacy,
confidentiality, informed choice, concern, empathy, honest, tact and sensitivity,” and
argued that the “interpersonal process is the vehicle by which technical care is
implemented and on which its success depends” (Donabedian, 1988). Importance of
clienLproyider interface was emphasised by some others in their pioneering work,
especially in areas of family planning (Simmons et al. 1986; Simmons and Phillips
1990; Simmons 1994). Eventually, Donabedian’s concepts formed the foundation for
Bruce-Jain’s model (Bruce, 1990;), generally referred to as ‘population council
model’. It was evolved in an attempt to evaluate ‘family planning programmes’, one of
the major ventures of the Council towards population control. The long awaited shift
in family planning programmes’ focus from fulfilling larger community’s reproductive
goals to individual woman’s own needs took place, at least hypothetically, because of
this model. Feminist health movement’s concerns that health care providers should
hear to women’s voices and perspectives on services experience were partially
addressed to by incorporating ‘process’ component in the assessment model of quality
of care. Most of the elements of the Bruce family planning framework are transferable
to a woman’s, health care framework (Mensch, 1994)
By adding the ‘process’ component as part of the ‘quality of care’ model, a space was
given to the users’ perceptions and expectations ofquality of care. Empowering clients
by providing them adequate, relevant information during provider-client interaction in
a legible manner has been considered as an important indicator of quality of care.
Population Council’s model is considered as a gender sensitive one but it doesn’t
enable researchers to identify or to measure the influence of gender in the interaction
between services and the population (Pittman, undated). It doesn’t really address the
issue of influence and impact of socio-cultural factors on attitudes of both - clients and
providers in a particular health care seeking situation. In that, the power relationships
arising from cla^s. (professional and social), ggnder etc. can’t easily be translated in
measurable indicators. This is to appreciate that the interactions between the users and
providers oF health care services do not take place in vacuum but they always have
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socio-cultural context. The most significant aspect, therefore, would be not only to
ensure that there is space created for such an interaction but further to ensure that such
a space will be made free of inequities between client and provider arising from above
mentioned factors.
5.2 Different context of family planning sevices and abortion care services
One finds hordes of literature based on the research on quality of family planning
program from all over the world. Researchers, by and large, used the concepts and
ideas put forth by Donabedian in 80s. Studies evaluating family planning programme
using the Jain-Bruce model are abundant in India, too (Gangopadhyay and Das, 1997;
Reddy, 1997; Foo, 1995; Levin et. al., 1992; ICMR, 1991). Asa consequence, in India
and even elsewhere, mostly public health care facilities have been covered. The private
health care sector, which contributed! .7(1 percent ^jfrthe-totaLhealth-care-services,
therefore, is less studiedjfrom quality of care perspective. We have earlier seen that
the share of the private health care sector in abortion care service provision is also of
this magnitude. In addition to these, family planning services and abortion care services
are different on various dimensions as shown in below.
The contexts of family planning services and abortion care services
Different aspects of services
Abortion care services
Family planning services
State’s perspective and role
1. Programmatic nature
No government programme for
Constitutes one of the
MTP services alone.
major programmes
But constitutes one of the
elements of the other
programme, such as, RCH
2. Period of Implementation
Made legal since 1971, but does
National programmes
of programmes, if any
not constitute state’s
implemented since 1951
programmes/package
3. Involvement of the private
Large share
Comparatively less
sector________________
4. State’s funding
Expected to be available free of Fully funded at the public
charge at public health care
health care facilities
_________ facilities_________
5. State’s financial support to
Marginally (Pearl centre,
Yes
private health care sector
Mumbai and Pari war Sewa
_________ Sanstha)_________
6. State’s interest_________
_____ Population control_____ Population control
7. Place in state’s population
Indirect and moderate
Direct and very prime
control drive__________
8. State’s concern for
Very low
Very low
woman’s health
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17
1. Socio-cultural acceptance
2. Stigma_______________
3. Moralistic values attached
Women’s perspective:_____
1. Nature of need
2. Attitude towards______
3. Awareness about its
legislative nature______
4. Prevalence of
misconceptions about its
medical consequences
5. Decision making
Socio-cultural perspective
_________ Very low______
_______ High degree
Very high
Almost desperate
Not very positive
Very low
Fairly well
Almost nil
No
Almost optional or
imposed by the program
______ managers______
Not very specific
Not applicable
Immaterial (does not affect
High
woman’s abortion seeking
______ behaviour)______
Very complex and dynamic
Less complex
Providers’ perspective
1. Market interest of private
High
Very low
practitioners__________
2. Cost of services
Very high
Free at the public health
care.
At private health care facilities
Available at cost at private
available only at cost.
health care facilities
Public health care facilities too
indulge in charging abortion
__________ care__________
3. Attitude towards
Not very positive
Positive
This comparative picture of abortion care and family planning services tells us that
their socio-cultural and political contexts are different. This, therefore, required us to
lay down a specific model for making an assessment of quality of abortion care. As
stated earlier, private practitioners are important players in abortion services. Though
abortion situations are not emergencies in medical sense, they are so for women in
need of abortion. These complexities around abortion required indicators of quality of
care to be defined differently than that of family planning services. However, the
commonalties are in terms of state’s and providers’ interests involved in provision of
these services. State is providing these services with an intention to control population
while medical fraternity by and large makes business out of it. Women’s needs and
health concerns feature only marginally despite much hue and cry about it.
6. QUALITY Oi ABORTION CARE : A MODEL
The structure-process-outcome model that is widely used to study quality of care
formed the basic premise for making an assessment of quality of abortion care (QAC)
services in this study. It also accommodates the six elements, which constitute the
much known and most frequently used Bruce-Jain model. The content of each of the
components and sub-components specific to abortion care services was defined based
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on (a) the scientific literature review of abortion procedures; (b) the MTP Act; (c)
women’s expectations about quality of abortion care that were captured in community
based empirical research with women; and (d) literature review of the women’s group
experiences while providing reproductive health care and abortion care services. The
first two mostly helped us to draw the medical indicators whereas the last two to draw
the non-medical indicators.
While conceptualising the indicators of QAC, it would be erroneous to ignore the fact
that abortion care services by and large are situated in the health care service
facilities. The present health care delivery system on the one hand and socio-cultural
fabric of abortion & its legal status on the other hand form the context in which
abortion care service delivery takes place. The QAC model is presented below
keeping this in mind. It offers the perspective and context for each of its indicators. It
explains in brief the significance of and contribution of these indicators to QAC. The
contents of these indicators and criteria for their assessment are presented in Table A.
6.1 Structure
The three aspects, access to ACFs, physical standards at ACFs and human power
(service providers) at ACFs constitute "structure’.
6.1.1. Accessibility
Access to health care services impacts utilisation of health care services. Empirical
research centred around utilisation of health care services has dealt with physical
access to health care. Not much empirical research one comes across which may have
mapped the health care facilities to study these two aspects at micro level. But there
are insightful analytical research work on these issues mainly based on national or state
level secondary data. The critical role that the health policies, resource allocations, and
priorities of the government play in shaping profile of health services have been the
common thrust of these works. Secondary data were used to critically examine distribution
of health care facilities (Nanda and Baru, 1994; Baru, 1993) highlighting the feet that
inequitable distribution leads to poor access for some and/or in certain areas. Ashish Bose
(1988) who studied the issue of physical accessibility in a few North Indian states
pointed out that little attention was paid tojvariation in size of settlement patterns in
the health pohey. This resulted in a blanket approach to the location_pf PHC facilities
irresggetive of population density orjize of settlements. Implications of side-tracking
these differences become even sharper when one takes physical accessibility in terms of
connectivity, i.e. how many villages are .linked with roads and availability of transport
facilities.
These problems as regards availability of and approachability to health care services
must have far reaching ramifications for their utilisation. This is because of the
complex relationship between these factors and the range of socio-economic status of
users of these services. This has been demonstrated by empirical research. For
example, the household survey of medical care documented that people from rural area
had to travel more than 10 km for taking treatment for illness, which increased the
average cost of treatment of illness. (NCAER, 1992). The complex and significant
Chi
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19
relationship among social-geography of health care facilities; the rural and urban based
users of health care services; the extent of remotely located users; their economic class
& purchasing power; and prevalence of illnesses was unveiled in an empirical research
on household expenditure in Jalgaon district, Maharashtra (Duggal & Amin 1989). The
study showed that despite higher prevalence of illnesses in remote rural areas, there
was underutilisation of health care services for the reasons of poor accessibility to
health care services and low or no purchasing power of the people there.
Many of the perspective and analytical literature critiqued the existing health care
delivery system from a point of view of women as users of these services. They
highlighted the need to understand prevalence of women’s illnesses and access to care
in the context of women’s time and work, the demands made on her by the family,
children and society, her status in the family the patterns of work related illnesses,
women’s low incomes and poor purchasing power in the unorgansied sector etc.
(Prakash, 1984; Sathyamala, 1984, Shatrugna, et. al. 1987). Many of the community
based research on prevalence of women’s illnesses, their utilisation patterns and
household health expenditure have demonstrated that there exists a complex inter
relationship between women’s status seen from the above mentioned perspective and
their access to health care services (Madhiwalla, 1999; Duggal & Amin, 1989). In
addition to this, empirical studies have demonstrated that women would use public
health care services provided they are available, approachable and would provide
quality services. (Gupte, et.al., 1999). Difficult physical access to health care services
and poor quality of health care provided were found to be correlates of poor or no
utilisation of health care services.
The far reaching ramifications that are being referred to will have an added edge on
account of indirect costs woman bears. Difficult access in terms of long distance,
inconvenient modes of travel implies longer time that she is away from the family. This
may result in loss of wages and leaving children and family unattended. The stress that
these women bear to manage to meet all ends is less talked of and less articulated both
by women themselves and by researchers in most of the empirical studies. But it would
not be difficult to imagine the extent of its burden on women.
Against this backdrop and given the social-cultural context of abortion, access to
abortion care has a special significance for women seeking abortion care. We, for the
present research defined access in terms of availability, approachability and
affordability. The content of these indicators and criteria for assessment are
presented in Table A.
6.1.2 Physical standards
Improved access to health care services may not necessarily result in its improved
utilisation. For instance, state’s efforts to improve access of the rural population to the
health care services by setting up primary health centres (PHCs) has not had the
expected impact of making primary health care universally and freely available. PHCs
are grossly underutilised primarily because they arc inadequately provided with staff,
medicine, equipment, transport etc (Gupta J P et al., 1992; Ghosh B, 1991; ICMR,
1991). This indicates that mere expansion of the health care services in the haste of
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meeting targets of covering maximum population did not really improve people’s
access to quality health care sendees.
In India it is since late 80s that aspects such as physical standards and availability of
appropriately qualified human power at medical health care facilities were paid
attention to by the health researchers and were viewed as one of the major
determinants of quality of health care services. The recognition to these aspects was in
the context of failure of people’s access to health care services despite its expansion as
mentioned above. The research on these aspects remained focused on an assessment of
quality of state’s family planning programme because state’s obsession with population
control. This relied mostly on the international model for various indicators and its
content. However, for assessment of quality of other types of services it is required to
lay down the framework; to define the specific indicators; and to determine measures
& means to assess them. The major constraint that has been eventually voiced by
health researchers was about not having any minimum physical standards laid down
against which assessment could be made. Some efforts were made in mid 90s to lay
down such minimum physical standards for making an assessment of the private health
care facilities. This initiated the process of enabling a rational assessment of the
minimum physical standards. It sharply brought out the need to have (a) such standards
laid down and (b) medical legislation/s to monitor institutions’ compliance with these
minimum physical standards.
For instance, in Indian context, the earlier research on physical standards at general
health care facilities had to develop the minimum physical standards, an exercise in
itself, against which an assessment could be made. (Nandraj & Duggal, 1997). While
doing so, a range of factors had to be taken into account, such as, type of health care
provision, number of beds. These therefore have made significant contribution to both,
understanding this aspect of quality of care and to methodologies of quality of care
studies.
Against this backdrop, abortion care services appear to stand out. This is because the
MTP Act has laid down specific guidelines about the minimum physical standards to be
maintained and training and experience for abortion service provider and anaesthetist.
There is not much research available on quality of abortion care, which has looked into
its various aspects. In a multi-state study on abortion care. Centre for Operations
Research and Training (CORT), Baroda, Gujrat, India has used the well-known
approach of situation analysis to study quality of abortion care. (Khan et al., 1998).
However, against the critique that we have posed on this particular aspect of the MTP
Act earlier in the present chapter, we included some additional complementary and
peripheral services and facilities as indicators of quality of abort ion care model.
Equipment, instruments, drugs, quality of space etc. constitute physical standards.
We, for the present study, classified them in categories such as ‘essentials \
‘complementary1 and ‘peripheral’ depending upon the extent to which fatality and or
risk to women could be caused because of their absence or unavailability. Also, in
general, ‘essentials’ are of critical importance from medical point of view whereas
complcmcntarics’ arc of much significance to women as users abortion care services.
Ch I
Introduction
21
Essentials: Lack of essentials subjects women to unsafe and even fatal abortion care
services.
Essential equipment, instruments and life saving/emergency drugs: We
considered the items listed in the clause (b) of Section 4 - Approval of Place,
of the MTP Act as essentials.
Essential facilities: In addition to the above, we included, availability of a
generator set, at least at the operation theatre, in ‘essentials’. All the women
are equally at risk at the ACFs, if are not fully equipped with essentials. The
risks at those with no generator set at OT are no less except that not every
woman necessarily would be subjected to it.
Complementary facilities: Complementary services are those without which having
in-house, abortion care could be provided. However, it is implied that they are
available in the vicinity. It is desirable to have them in-house.
Availability of these essentials and complementaries at ACFs is the criterion for
an assessment of these indicators.
6.1.3 Human power:
Adequate and qualified staff contributes to safe health care delivery. In case of
abortion care, heads of institutions (HI), abortion care providers (AP), consultants,
anaesthetists (AN), laboratory technicians (LT), nurses/paramedics, aayas, ward boys,
enquiry attendants and social workers constitute human power at abortion care service
facilities. While qualified abortion care service providers and anaesthetists are
essential services from medical point of view, the other services are important from
women’s point of view.
Essential service providers:
AP and ANQ: The MTP Act has laid down minimum qualifications for
abortion care service provider and for anaesthetist.
Complementary service providers:
LT: Service provision by in-house laboratory technician (LT) are not essential
at ACF either legally or medically. However, it is essential that providers
prescribe/conduct some minimum diagnostics, such as, urine test, blood group
and Hb count, for abortion seeking women keeping her safety at the centre. In
house technician and the related services save woman trouble of getting tests
done from outside.
Lack of in-house laboratory facilities implies that women have to get the tests
done from outside of a ACF when they are prescribed. It may mean that she
has to forgo her concern for confidentiality. .Also, in this age of rampant
4
Chi
Introduction
22
practice, this will have additional potential for women to get exploited
monetarily.
4
Nurses: The central MTP Act does not include nursing care as part of the
essential abortion service package. However, the Maharashtra state level ‘Rules
and Regulations’ complementary to the central MTP Act make the nursing care
essential. It states that the nurses assisting through abortion procedure should
either be degree holders or certificate holders. However, we did not include
them in ‘essentials’.
Aayas and ward boys: These constitute the complementary staff at any health
care facility. Their significance is necessarily because they contribute greatly to
maintenance of and cleanliness at ACFs in various ways. They attend to non
medical needs of clients adding to latter’s comfort and conveniece.
Social worker: Abortion care services in the West have demonstrated that
women centred counselling services do help women in these critical situations
of abortion seeking. This facilitates helping them release the stress and guilt
feeling caused by undergoing an abortion. Counselling also has a potential to
educating women about contraception and help women avoid repeated
abortions thereby reducing at least to some extent their burden of reproductive
labour. It has long lasting positive implications for women’s health.
In Indian context it perhaps is an over expectation given the poor status of
health care delivery system in general. However, counselling services need to
be offered to women. It can be done either by of the staff members, such as,
nurses and/or providers themselves. Assessment of this indicator, therefore, has
been done accordingly.
Availability of various service providers at ACFs; the type and the extent of
their professional training and experiences were the criterion for assessment of
these indicators.
6.2 Process
The process component has both, medical and non-medical aspects. The focus is on
how health care is delivered to its clients’ in the given structure of a health care
facility. Though existence of quality structure is a prerequisite, it may not necessarily
mean quality ‘process’ of health care delivery. For instance, an appropriately qualified
AP in an appropriately equipped health care facility unless seeks sufficient information
from woman and provides her adequate relevant information; screens and monitors the
woman appropriately; conducts all the minimum required post-operative examinations;
communicates her dos and don’ts; and counsels her to avoid unwanted pregnancy in
the future, can’t be treated as quality care.
Research has demonstrated that utilisation of health care and choice of provider are
determined also by factors such as the extent of waiting period, attention paid to user’s
perception of their own illness, the extent of information exchange and counselling,
*
C/i i
Introduction
i
142
----------------
’
23
4
the extent to which providers’ are inclined to seek active involvement of users of
services; careful examination and checking, quick admission, the extent of respectful
treatment etc. (Gupte et. al., 1999, Reddy, 1997; Iyer et.al., 1996; Gangopadhay &
Das, 1993; Levin, et. al., 1992, Visaria &, Visaria, 1990;). This implies that the gap
between users’ expectations from health care delivery system and their perceptions of
quality of care must assume importance in delivery of health care for its optimum
utilisation.
In India, it is five decades since the family planning programme is being implemented
intensively and supported by large resources. And yet it did not help meet either
people’s contraception needs or state’s population control goals. Reasons for failure of
family planning programme are now being located in the way the services are being
delivered. Ramasundaram (1994) attributes poor quality of family planning programme
to attitudes of health worker^ who .showed little respect for clients, especially if they
were poor, illiterate, or from lower social strata. Among many others, the factors that
can affect service quality are the failure to provide adequate information to acceptors
of family planning methods; the f^lurejtp_check_ clients for contraindications before
inserting intrauterine devices etc. (Word Bank, 1995). Synthesis of 28 research studies
from all over India on quality of family planning programme demonstrated that
interpersonal dimension of quality of care is quite poor. (Foo, 1995). The power
relationship between providers and clients, cultural gap and the vast knowledge
differentials between them were the various factors those affected/influenced these
interactions.
The quality of care model defines process’ in terms of four sub-components. They are
provider-user information exchange; provider competence; interpersonal clientprovidej^relations and continuity. Their content for assessment of family planning
programme is well defined. However, their objective assessment still remains difficult.
As far as the interpersonal interactions and information exchange is concerned, it
remains difficult to influence ‘how’ aspect of communication delivery for improving its
quality as there exists a range of intervening factors. The difficulties are also on
account of the fact that the intervening factors are of ‘behavioural’ nature, such as,
providers’ attitudes towards, for instance, women and abortion, providers’ perceptions
of women’s abortion needs, their convictions and beliefs about power of
communication with and counseling to clients. In addition to this, the difficulties that
arise while assessing ‘providers’ competence’ are of different nature. Case to case
variation - client’s needs and circumstances and provider’s response to it - makes it
arduous to standardise the indicators which would measure quality of‘process’. These
studies have also indicated that it is difficult to quantify this indicator. The efforts
always have been to demonstrate the quality of‘process’, that is how appropriately and
adequately health care services are delivered meeting specific needs of a particular
client of health care — family planning — services with the help of narratives/case
description drawn from data collected through observations.
In the context of abortion care, neither the MTP Act nor any other medical legislation
has laid down any specific criteria or guidelines for providers while interacting with
abortion seeking women. However, one finds elaborate guidelines in the medical text
books for medical providers while conducting abortion procedures. The thrust of these
Ch 1
Introduction
24
4
has been on medically significant checks and tests to be done pre and post abortion as
well as precautions to be taken during the procedure. We, therefore, operationalised
the concept using these as foundation. In addition, documentation available of
experiences of women’s groups as regards women’s health care were used, especially
while operatonalising the soft-facets of process, such as, client-providers interpersonal
interactions.
Provider-user/clients information exchange: This refers to listening to and
understanding a woman. It involves (a) Obtaining information on & (b)
Conveying/informing the client about
Provider competence: This refers to technical competence and proficiency of
abortion service provider. It includes screening, management and monitoring
Interpersonal relations (Client - provider relations): This refers to the sensitive
treatment of women.
Continuity: This involves giving information a) about when to return and, other
locations where services and medications can be obtained, and b) specific follow-up
procedure.
As stated earlier, assessment of ‘process’ component has remained difficult.
However, they are assesses by observing client - provider interactions for their
texture, content, appropriateness and adequacy.
6.3 Outcome
It was the poor ‘end result’ which initiated the thought processes to look into how the
services are delivered. Outcome of health care delivery is one of the major indicators
of quality of care. Indicators of outcome are (a) biomedical and (b) sociobehavioural.
In the present context of abortion services, they are conceptualised as follows:
Researchers found it difficult to get hard data on biomedical indicators, both in
retrospective and prospective study designs, especially in developing countries. The
former approach may be impractical because of lack of accuracy and the latter because
of limited resources available.
Sociobehavioural indicators of quality of care are sensitive and are to be used very
cautiously. Sensitivity of these indicators is on account of the fact that they are more
participatory and accommodative of user’s perception and evaluation. Responses about
‘users’ satisfaction’ are often guided by socio-cultural values. They can neither be
considered as perfect indicators of ‘quality of abortion care’ nor can their socio
cultural context be under estimated. One may get entrapped in the prevalent cultural
and structural value system by treating “users’ satisfaction” as the sole indicator of
‘abortion care’. It is the researcher’s responsibility to strike the balance between
objectivity and subjectivity.
Chi
Introduction
25
9
Biomedical indicators
These refer to absence of post-abonion complications, sepsis, infections, deteriorating
health or menstrual problems on account of contraceptive, any kind of uterine
problems which could be associated with the abortion procedure, incomplete
abortions, mortality and morbidity resulting out of these and any difficulties in
conceiving which could be associated with the abortion procedure.
Socio-behavioura! indicators: Refer to women’s/users satisfaction with the abortion
care services. They are mostly related to their perceptions of the delivered services.
Table A
QAC: INDICATOR AND THEIR CONTENT
CRITERIA/METHOD FOR
ASSESSMENT
STRUCTURE
Accessibility____________
B Availability (non-medical)
" Existence
. ■ Adequacy
Approachability(non-medical)
■ Distance to ACFs,
■ Approach roads,
______ * Transport facilities________________
■ Affordability (medical & non-medical)
■ Travel cost,
■ Fees for abortion care, cost of
medicines, diagnostics tests conducted
______ " Other costs (stay, food,____________
Physical standards______
" Spaces and their condition_________________
______ " Operation theatre* (medical)________
■ Others (non-medical)
(waiting room, consulting room, wards,
__________ special rooms, sanitory block)______
■ Essentials____________
■ Equipment and related infrastructure*
(medical)
111 Anaesthetic equipment
■ Resuscitation equipment
■ Sterilisation equipment
* Operation table_________________
■ Instruments (medical)
■ Required for abdominal/gynaecological
surgery*
g Required for laparotomy**
■
Ch I
Introduction
H
■
■
“
■
B
B
Share of HCFs in abortion care
service provision,
Adequacy in terms of meeting
women’s abortion care needs_____
Spatial distribution,
Availability and type of road
Transport facilities used
Time taken to reach ACFs_______
Cost incurred by women
a
for travel
□
for abortion procedure, drugs,
diagnostics
others
H
8
■
Availability and hygienic condition
Availability and cleanliness
Availability
Availability
26
Essential drugs (medical)
■
■ Required for the abortion procedure*
■ Required for administering anaesthesia*
■ Parenteral fluids*
___________
s
Facilities (non-medical)
■ Power back up such as generator
set
■ Fire extinguisher______________
■ Complementary facilities (non-medical)
■
■ Telephone,
■ Ambulance,
______ " Food______________________________
Human power________ _______________________
" Essentials (medical) ________________________
______ " Abortion service providers*_____________ ■
■ Anaesthetists*
■
■
Complementary_______________________
* Laboratory technician (medical)
■ Paramedics (Nurses) (medical)
■ Paramedics (aayas, wardboys etc.)
__________(non-medical)__________________
______ * Social worker (non-medical)_______
■Peripherals (enquiry attendant) (non-medical)
Availability
Availability
Availability
Availability of qualified allopaths
Availability
of
qualified
anaesthetist
"
__________________________________ PROCESS
Provider-user/clients information exchange
(non-medical)_________________________________
■ Obtaining information on:
■ background including details about her last
menstrual cycle,
■ reasons to undergo abortion,
■ contraceptive history,
■ reproductive intentions and
■ overall current health status and history (any
major illnesses in the past she has suffered
from); and
■ Conveying/informing the client about:
■ length of gestation,
■ methods to be used,
■ risks involved,
■ legal requirements, and
■ precautions to be taken before coming for
abortion, if she decides to undergo, and after
operation safety measures.
Chi
Introduction
■
■
E
Availability of in-house LT______
Availability of trained nurse and
others
Availability
Availability
Woman - provider interactions
were observed for their content,
texture,
appropriateness
and
adequacy.
27
Provider competence: (medical)
■ Screening
■ Accurate diagnosis of the gestation period
Screening: Observation of cases
■ decision about appropriate abortion method to
be used
■ ability to foresee probable complications during
the procedure
Management: We did not assess this
■ Management
facet
■ Technical proficiency in providing safe and
appropriate clinical abortion method depending
upon gestation period and her health status
■ Monitoring
Monitoring: Oservation of cases an
■ Involves detecting blood group, checking blood assessment on these indicators
pressure, hemoglobin percentage, weight,
______ urinary tract infection etc._________________
Interpersonal client-provider relations
Observation of cases
(non-medical)
■ Maintaining privacy
■ Respectful and responsive provider behaviour
■ Encouragement of women’s participation in
decision making
■ Avoiding moral judgement
■ Maintaining confidentiality
■ Limited waiting time and quick appointment for
the actual procedure
Continuity (non-medical): This involves giving Observation of interactions to examine
information
whether it takes place.
■ About when to return and other locations where
services and medications can be obtained
* Specific follow-up procedure
OUTCOME
Biomedical (medical)
■ Absence of post-abortion complications, sepsis,
infections,
■ deteriorating health or menstrual problems on
account of contraception
■ any kind of uterine problems which could be
associated with abortion
■ incomplete abortion, mortality and morbidity
resulting out of these
■ any difficultires in conceiving which could be
associated with abortion procedure
Sociobehavioural (non-medical)
0 Women’s satisfaction with abortion care
services
________________________
Recording morbidities occuring
immediately after abortion either by
observing, interviewing or examining
the case papers.
Collecting women’s perceptions
and satisfaction about abortion care
services received by them.
* rhese are stipulated in the MTP Act. ** These are stipulated in the State's Rules and Regulations
Chi
Introduction
28
1. Salient features of the study
The present research has an advantage of continued and consistent involvement of
CEHAT in abortion issue. The two of the stakeholders in abortion care are women and
the service providers. We gathered women’s perspective on abortion from our earlier
community based work with women. This provided the context to conceive this
research. With this grounding in the issue, studying quality of care made a difference.
This research though exploratory’ in nature, could bring out some complex analysis of
the abortion care situation.
■
It defined 'safe and legal abortion care’ from not only the perspectives of medical
sciences but also from women’s perspective and assessed quality of abortion care
that prevails today. Such an assessment of quality of abortion care would provide
us with not only facts and figures but also to tap the gap between the minimum and
prevailing so as to enable design remedial measures to improve the conditions.
■
It took into account the entire health and abortion care service sector by
enumerating the health and abortion care facilities in the study area.
■
The study units are public & private; registered & non-registered; and urban &
rural. It for the first time private non-registered abortion care facilities are studied
in details and in-depth.
■
It assessed quality of abortion care against the model evolved taking into
consideration both, the medical and non-medical aspects of quality of care. This,
therefore, has provided space for women’s perspective on quality of care. The nonmedical indicators were evolved from a woman centred community based abortion
research.
■
It studies all the three components of quality of abortion care thus providing
insights into the issue in a comprehensive manner.
■
The composite analysis of medical indicators (essential physical standards and
qualified human power) at the level of individual abortion care facility made it
possible to assess an individual unit for quality of abortion care comprehensively
beyond the level of individual indicators. This clearly brought out the enormity of
the problem of institution based unsafe abortion care services.
■
It is for the first time the role of abortion service providers as 'gatekeepers’ irf the
context of abortion care service delivery is studied demonstrating the over
medicalisation of abortion services..
■
While it made an assessment of the abortion care services, it also studied providers
perspectives and views about the women’s abortion needs and MTP legislation.
Chi
Introduction
29
Table 1.1: Legal Abortions
Year
1972-76
1976- 77
1977- 78
1978- 79
1979- 80
1980- 81
1981- 82
1982- 83
1983- 84
1984- 85
1985- 86
1986- 87
1987- 88
1988- 89 .
1989- 90
1990- 91
1991- 92
1992- 93
1993- 94
1994- 95
1995- 96
1996- 97
No of
Approved
Institutions
1877
2149
2746
2765
2942
3294
3908
4170
4553
4921
5528
5820
.6126
6291
6681
6859
7121
7374
7628
8511
8722
8891
Increase in no. of
Institutions over
previous Year.(%)
27.8
0.7 '
6.4 '
12.0 '
' 18.6 '
6.7 '
9.2
8.1
12.3 '
5.3 '
5.3 '
2.7 '
6.19 '
2.66 '
3.82 '
3.55
3.44 '
11.58 ~
2.48 '
1.94 '
No. of MTPs
perfonned
381,111
278,870
247,049
317,732
360,838
388,405
433,527
516,142
547,323
577,931
583,704
588,406
584,870
582,161
596,357
581,215
636,456
606,015
612,291
627,748
570,914
538,075
Increase in No. of
MTPs over
previous year (%)
-11.4
28.6
13.6
7.6
11.6
19,1
6.0
5.6
1.0
0.8
-0,6
-0.5
2.4
-2,5
8.8
-4.78
1.04
2.52
-9.05
-5.75
Average
No. of MTPs
per Institutions
_______ 130
________ 90
_______ 115
_______ 123
_______ 118
_______ 111
_______ 124
_______ 120
_______ 117
_______ 106
_______ 101
________96
________93
________ 89
________ 85
________ 89
________ 89
________ 82
________ 80
________74
66
Source : Family Welfare Year Books, 1988-89 and 1996-97, Government of India..
Chi
Introduction
30
Table 1.2 : Statewise MTPs and Government Approved Institutions 1993-94
Population
Percentage
Institution
share of
population
ratio
(1996)
Andhra Pradesh
13719(2.3)*
373 (4.0)*
36.8
193,445
72,155 _______ 7,7
24,726 ' _______ 2.7
Assam________
21372 (3,5)
100(1.1) 213,7
247,260
93,005 '
Bihar_________
11060(1.8)
209 (2,3)
52.9
445,000
10.0
45,548 ' _______ 4,9
Gujarat______
10263 (1.7)
700 (7.6)
14,7
65,069
18,553
'
Haryana______
22438 (3.8)
228 (2.5)
98.4
_______ 2.0
81,373
49,344 ' _______ 5.3
Karnataka_____
__ 9077 (1.5)
104 764
471 (5.1)
19.3
Kerala________
34433 (5.7)
559 (6.3)
61.6
30,965 _______ 3.3
55,394
74185 ' _______ 7.9
Madhya Pradesh
33086 (5.4)
295 (3.2) 112.2
251,475
86,587 ' _______ 9.3
Maharashtra
97079 (15.9)
48,781
1775 (19.2)
54,7
Orisa_________
19510(3.2)
34,440 _______ 3.7
203,787
_ 160 (1 8) 115.4
Punjab_______
19436 (3.2)
242 (2.6)
80.1
22,367 _______ 2,4
92,426
Rajasthan_____
29023 (4.8)
316(3.4)
91,8
_______
5,3
157,354
49,724
Tamil Nadu
42364 (6.9)
623 (6.7)
68.0
59,452 _______ 6.4
95,429
Uttar Pradesh
12103 (2.0)
425 (4.6)
28.5
156,692 _______ 16.8
368,687
West Bangal
64273 (10.5)
452 (4.9) 142.2
74,601 _______ 80
165,047
Other states
170679(28.0)
2334 (25.2)
73.1
41,874 _______ 4.5
17,941 .
India
__________________________________________________
_
__________________
609915 (100.0)
100,768
I
9271 (100.)
62.7
934,218
100.0
State
No of MTPs
No of
Institutions
MTP
Inst.
Ratio
State
population
1996 (‘000)
Data are taken from Government of India. Ministry of Health and Family Welfare. Family Welfare Program in India. Year Book (1993-94).
Nirman Bhavan, New Delhi: Ministry of Health and Family Welfare, (n.d.)4
* Figures in paranthesis are column percentages
4
Chi
Introduction
31
\
Table 1.3 Estimated number of abortions
Year
Population
(inmillion)
No of live
births
(in million)
CBR
1991
1992
1993
1994
1995
1996
1997
843,9
861,7
877,0
892,5
907.8
923,1
938.2
24.9
25,2
25.2
25,6
25,0
23.0
23.4
29.5
29,2
28.7
28,7
27,5*
24,9*
24.9*
Total
abortions
in the year
(in million)
______ 8,5
______ 8.6
______ 8.4
______ 8.8
______ 8.6
______ 7.9
8.0
Induced
abortion
(in million)
Spontaneous
abortions
(in million)
5.1
5.2
5,0
5,3
5.2
4,7
4.8
3,4
3,4
3,4
3,5
3,4
3,2
3.2
Abortion
rate
(per 1000
popn)
10.1
10,0
______ 9.8
______ 9,6
______ 9.5
______ 8,6
8.5
Abortion rate
(per 1000 live
births)
341
341
333
344
342
343
341
* Source : Government of India. Planning Commission , Eighth Five Year Plan: 19992-1997, vol I, New Delhi, 1992 (the figures are extrapolated)
Source for data on population and CBR otherwise : Data Base, CEHAT, Mumbai-Pune, India. The data used in this data base is drawn from
various government sources.
How have we arrived at the statistics on ‘total number of abortions’?
The Shah Committee (1966) assumed that for every 73 live births there are 25 abortions. It also assumed that of the three-fifths of these are
induced and two-fifths are spontaneous.
Accordingly then, Number of estimated abortions = No of live births x 25/73
or
= Crude Birth Rate x Population 25
x —
1,000
73
fable 1.4 Proportion of legal (MTPs) to illegal abortions: An estimation
Year
1991
1992
1993
1994
1995
1996
1997
Total number of
Induced abortion
(in million)
_____________ 5.1
_____________ 5,2
_____________ 5.0
_____________ 5.3
_____________ 5.2
_____________ 47
4.8
Total Number of
MTPs
(in million)*
.58
.64
.60
.61
.63
.57
.54
Total number of
illegal abortions
Proportion of
legal to illegal
4.5
4,6
4.4
4.7
4.6
4.1
4.3
1:7,8
1:7,2
1:7.3
1:7.7
1:7.3
1:7.3
1:7.9
‘Source: Family Welfare Programme in India, Year Book, 1996-97
Table 1.5 Estimates of Number of induced abortions nationwide annually
Source
Shah, 1966___________
IPPF, 1970___________
Goyal et al, 1976______
Unicef, 1991__________
GO1, 1991-92_________
Chhabra and Nuna, 1994
CEHAT, 1997______________ __
Number of Induced Abortions Nationwide
________________ (Millions)___________
________________ 3.9________________
________________ 6,5________________
________________ 4,6________________
________________ 5.0________________
________________ 0,6________________
6.7
4.8*
* Using Shah Committee formula . extrapolated population and birth rates for 1997. Government of India, Planning Commission 8th FYP 199297, Vol I, New Delhi, 1992
Chi
Introduction
32
Table 1.6 Percentage of abortion deaths to child birth and pregnancy (maternal).
All India (Rural)
90
86
88
89
93
85
87
80
81
82
83
84
Year
78
79
11.7
11.0 11.7 12.5 13.7
8.0
7.6
5.0
10.9
11.8
11.5
10.1
10.8
Abortion_______________________
_____10.7
____ _________________________________________
94
12.6
95
17.6
Sources : Model Registrar Scheme, Survey of Causes of Death(Rural) 1984-1996- A Report, Series 3 No. 17-19, Statement No. XIX, Registrar. Gen. Of India,
New Delhi.
Government of India Survey of Causes of Death (Rural), Annual Report, 1990 Office ofthe Registrar. Gen. of India, New Delhi.
Table 1.7 Abortion related causes of Maternal deaths*
Percent of Maternal Mortality Attributable to Abortions
Location_____________________________
_______________________
15.1_____________________
Selected Hospitals 1978-81_______________
_______________________ 11.9_____________________
Anantapur District, Rural and Urban, 1984-85
_______________________
16.9_____________________
India, Urban, 1985______________________
_______________________ 4.5______________________
Karnataka, Rural, 1989__________________
_______________________
10.8_____________________
India, Rural, 1989
___________________
_______________________ 11.7_____________________
India, Rural, 1993______________________
18.0
India, 1991-95____________________________________________________________________________
Sources: World Bank, 1996, for .Anantapur (Bhatia, 1988); for Karnataka (Reddy. 1992); for India niral 1989, (Ofifce of the Reg Gen, GO, 1991); 1993
(Ofifce ofthe Reg Gen, GO, 1993); for India Urban (Ofifce of the Reg Gen, GO, 1998); for selected hospitals (Rao, 1988); for India 1991-95(001, 1991-95)
as cited in (Matha 1998)
♦Source: Heidi Bart Johnston (1999). Abortion and postabortion care in India a review ofthe literature.
Chi
Introduction
33
CHAPTER H
STUDY DESIGN AND METHODOLOGY
1. Selection of the study area
2. Sampling
3. Collection of data
3.1. Quantitative survey
3.2. Qualitative case studies
4. Data analysis and presentation
5. Problems encountered
6. Methodological and ethical issues
Various methodologies have been tried out to study the three fundamental components structure, process and outcome. The most used is a situation analysis (SA) methodology,
a research tool that was developed by the Population Council to describe what a family
planning program looks like at the grass-roots level. (Mensch et al., 1994). It is one of the
approaches to translate the quality of care model to be useful at the field level. (Miller et
al, 1992). It primarily involves studying the service delivery points/ centres. It mostly uses
a combination of quantitative and qualitative methods/ tools of data collection. It provides
a comprehensive package of methodological tools to assess quality of care. Some standard
instruments are used in all SA studies. They include, an inventory for facilities available
and services provided at the service delivery point; an observation guide for interaction
between the consenting family planning client and the service provider; an exit
questionnaire for family planning clients attending the service delivery point; and an
interview schedule for staff providing family planning services at the service delivery point;
and an interview schedule for staff providing family planning services at the service
delivery point. Over the years research in this area have brought refinements in the
methodologies, especially to study ‘process’. Ethical issues involved are discussed and
articulated, though not resolved completely. A range of methodologies and issues involved
therein while studying client-provider interactions are discussed at length by Simmons
(Simmons and Elias, 1994).
In the present research, the QAC model that we laid down guided the methodology
entirely, including selection of the appropriate method of data collection, designing the
tools of data collection and their content. We conducted the study in two subsequent
phases. In that a quantitative survey was followed by an in-depth qualitative study of the
sub-sample. The former was designed primarily to assess ‘structure’ component of QAC
whereas the latter was to assess ‘process’ and ‘outcome’. In addition, we undertook an
enumeration of health care facilities (HCFs) in the study area to define universe for the
study. Such an enumeration was essential in absence of availability of any data on
abortion care facilities (ACFs).
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1. SELECTION OF THE STUDY AREA
Selection ofDistricts
The study was restricted to two districts, Pune and Ratnagiri of the state of Maharashtra,
India. They were selected using relative development status of the districts, as a primary
criterion and relative status of urbanisation as a secondary criterion. Development status
of a particular area has a significant bearing on the physical standards of health care
facilities. (Nandraj & Duggal, 1997). Also, with urbanisation, a change is expected in
people’s lifestyle. We anticipated links between people’s enhanced economic status and
accentuated expectations about the quality of health care facilities that they access, on the
one hand, and quality of care on the other. If so, the developed areas may score better on
indicators of quality of care.
Pune and Ratnagiri occupying opposite ends on the continuum of these two indicators
were selected to ensure that a reasonable range of variation is captured. With regard to
Relative Index of Development (RID), Pune (157 points) topped the list after Mumbai.
Ratnagiri and Latur occupied the lowest positions having the same RID values (51 points)
(Table 2.1). As regards their relative status of urbanisation, Pune (50.74) and Ratnagiri
(8.94) though did not follow exactly the same order as above, did fall into one among the
highest and lowest percentage of urbanisation respectively. Latur (20.39) occupied one of
the middle range positions and much above Ratnagiri with regard to its urbanisation
status. Latur, therefore, was dropped. High rate of out-migration was an additional
consideration in case of Ratnagiri. Inverse relationship between migration and fertility are
fairly well established (Bhatia & Sabagh 1980; Srutikar, 1980; Singh, Yadava & Yadava
1981).
Selection of talukas
In absence of any systematic and adequate data either on health care or abortion care
facilities or number of reported MTPs, we selected talukas based primarily on the
proportion urbanisation. (Table 2.2(a) & (b)). The added consideration was sex ratio.
(Table 2.2(a) and (b)). Generally, it appears that talukas with low proportion urbanisation
show comparatively more favourable sex ratios. The data on registered abortion care
facilities (R-ACFs) show that some of the talukas did not have a single private R-ACF.
(Baramati, Indapur, Mulshi, Shirur and Velhe from Pune district and Rajapur and Guhagar
from Ratnagiri district). (Table 2.3). Lack of R-ACFs would imply high incidence of illegal
abortions and/or women travelling long distances for getting MTP services. It has direct
consequences for quality of abortion care that women receive. Inclusion of these areas in
the study was also intended to capture the range of problems, if any, as regards the MTP
registration procedure.
More than one talukas from higher and lower proportion urbanisation were picked up
when the required sample could not be drawn from one single taluka.
The study area is shown in Fig 1.
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2. SAMPLING
Sample size
The size of the sample was fixed at 100 ACFs for a quantitative survey and size of the
sub-sample at 20 ACFs for in-depth case studies. This number seemed sufficiently large to
capture variations across the three analytical categories of the ACFs based on their
location, MTP registration status and public/private sector, if any. In absence of any data
on ACFs, we arbitrarily decided to cover 40 ACFs each from private registered and non
registered categories and 20 from the public sector. (Table 2.4). However, the sample
emerged differently from the proposed one basically for two reasons. One, the large
number of NR-ACF constituting the universe could actually be identified, unexpectedly.
Two, we tried to adjust the sample size at taluka level not to loose on having an adequate
representation from the selected talukas. Finally, 115 ACFs were included in the
quantitative survey of which 23 were studied in-depth qualitatively. And we could
study woman-client interactions for 40 women who sought abortion care from these
23 ACFs. The increased sample size than proposed one is because of our anxiety of large
drop out and/or no response, which in reality did not happen at all.
Selection of the study units
The only data available on ACFs were those at Directorate of Health Services (DHS),
Mumbai and at the Zilla Parishad and or Civil Hospitals. The former contained district
wise information about private R-ACFs while the latter provided information about the
public health care facilities (HCFs) engaged in abortion care services. This would leave a
large number of NR-ACFs out of purview of the study, if study units were limited only to
this domain. In absence of well defined universe from which this sample could be drawn,
we relied upon our own enumeration of the health care facilities in each of the selected
taluka. The data on all the public HCFs, and of those engagaed in abortion care service
provision in the study area were obtained, from the government sources as stated above.
For enumerating private health care facilities, we used snow ball method using various
sources. These included lists available with the local medical associations, pharmacists’
shops, health care providers themselves, and lists of the health care institutions/providers
obtained from the pharmaceutical company. The specialised health care facilities, for
instance, an ENT center, were excluded from this enumeration, assuming that they
possibly would not engage themselves in obstetrics and gynaecological and abortion care
services.
Enumeration of HCFs in the rural areas may have been less than perfect as we relied
mostly on the various sources mentioned above but did not practically visit each and every
village in the study area, unlike what we did in the urban and semi-urban areas.
During enumeration we obtained data from each of the HCF? on structure and type of the
institutions, whether it provides abortion care, qualification of head of institution (HI),
abortion care service providers (AP), if it provided abortion care services, and its MTP
registration status. (Annexure 1).
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Based on this enumeration and keeping in line with the proposed sampling framework, we
selected the study units purposively. This inclusion turns out to be about 72 per cent of the
total ACFs (universe) in the study area. (Table 2.4(b)). In case of Pune district, NR-ACFs
constitute about 57 per cent of the sample and the same for Ratnagiri constitutes 85.3 per
cent. The number of public ACFs and the private R-ACFs in the enumerated HCFs was so
meagre that to have an adequate number of units in the sample from selected talukas and
districts, we had to include almost all of them. Consequently, to have an adequate
representation from each of the taluka, we compensated the deficit in these categories,
especially R-ACF, by including more number of NR-ACF. The better strategy would have
been to undertake enumeration of the entire study area at a stretch before arriving at a
sample frame. Nonetheless, inclusion of a large number of ACFs from various categories
in the sample would be able to provide adequate representation despite the sample
emerging differently from the proposed one. Also the fact that the proportionate
percentage of the sampled units over various categories is comparable to that of the
universe suggests that selection bias, if any, of the researchers has been equally distributed
over these categories. (Table 2.4(c)).
Thus, such an exhuastive enumeration of HCFs in the study area helped us in more than
one ways, (a) It defined the entire health care service sector, both public as well as
private, in the selected area, (b) It delineated the universe for this specific study by
identifying all the abortion care facilities, a sub-set of the health care service sector, (c)
It helped us interact with the medical fraternity on a one-to-one basis, which contributed
a great deal in the subsequent phases, (d) It helped prepare ground for the subsequent
phase of the quantitative survey as we used this opportunity to communicate them
adequately. about our study, especially about significance of their participation and co
operation in the later phases of the data collection.
3. COLLECTION OF DATA
The data were collected in two phases. The first was a quantitative survey of the 115
ACFs followed by an in-depth qualitative study of the sub-sampled 23 ACFs.
3.1 Quantitative survey
The quantitative survey was primarily designed to collect data for an assessment of
'structure'. The QAC model provided the framework for designing the tools of data
collection. Besides, perceptions of both providers and heads of the institutions on some
key issues were gathered through this survey. These were obtained mostly through open
ended questions.
Tools of data collection
Separate interview schedules were designed for His and for APs (Annexure 2(a), 2(b)).
Acquiring information on human power and profile of abortion care services offered were
the thrust areas of these tools. These were complemented by an observation guide,
which was primarily designed to collect data on physical standards as defined in the
QAC model. (Annex 2(c)).
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Other important heads of data collection were as follows:
Providers1 perceptions about the MTP Act: This was included primarily to assess
knowledge of the medical fraternity about MTP legislation. It was also to know their
opinions about the stipulated qualifications for doctors, assistant providers and nurses;
opinions about the quality of the existing MTP training facilities and other related matters.
This, we assumed, have a bearing on women’s access legal abortion care service. This was
also intended to unravel the range of issues involved in MTP registration procedures. This
would directly feed into advocacy for safe and legal abortion care.
In this, the HI schedule contained questions related to MTP registration and stipulated
physical standards, whereas the AP’s were asked about the stipulated qualifications of the
providers, assistant providers, nureses, MTP training facilities etc.
Providers ’5 perceptions about women's abortion needs: A set of questions were included
to understand perceptions of His and APs about women’s abortion needs and its socio
cultural context. These are the potential/latent determinants of quality of abortion-care,
especially of the client-provider interactions. Without understanding these socio-cultural
constructs around abortion, we would loose on an holistic understanding of quality of
abortion care and dynamics involved therein.
Abortion providers as gatekeepers: A set of hypothetical questions were designed to
capture as to which situations and circumstances of women would they accept women’s
request for abortion care services. Questions were articulated to assess as to how
woman’s marital status, husband’s consent and her willingness to accept post-abortion
contraception impact providers’ decision about offering women abortion care services.
Pilot testing
All the tools of data collection were pilot tested in the Pune city and sub-urban areas.
Tools were revised based on the feed-back and experiences of the pilot test. Some of the
questions required restructuring and we also reorganised the sequence of questions to
bring about a smoother flow in the interview schedules.
Conduct of the quantitative survey
We conducted our quantitative survey, including enumeration during the last quarter of
1997 for about 2 and a half months with a longish break in between because of Diwali
vacation. The quantitative survey followed immediately after enumeration in a particular
area. A team of four field researchers was engaged in data collection. Of them, two were
working on the project almost from the beginning and were part of the processes involved
to reach the stage of conducting the field work. The other two joined a month before
actual field work started. Both had background of working in health. One each from the
former and the latter formed the two functional teams for the fieldwork. However, it was
flexible for them to either work in teams or independently as per the situation.
We conducted rigorous training before getting into the field. This had a special
significance since the subject matter demanded not only an understanding of the issue at
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hand but a good grasp of medical aspects of abortion and medical vocabulary in general.
Following were the thrust areas of training.
a) Getting well oriented with the content of the project (medical, socio-cultural and legal
aspects of abortion) and its theme. This was achieved through discussions and overall
orientation about abortion as an issue pf women’s health and women’s rights and
unsafe abortion as a public health issue.
b) Getting well versed with the medical and legal vocabulary. This was achieved by
preparing a detailed glossary of various medical terms related to abortion, instruments
and equipment. The field researchers could use this glossary during their field work as
and when required (Annexure 4). Besides, the entire team visited a gynaecological
health care center to learn in detail about the drugs, equipment and instruments and
understand the set-up at health care facilities. We also had a session with the
gynaecologists to understand the abortion procedures from medical point of view.
Senior researchers had studied the medical text books concerning the abortion
procedures and women groups’ experiments in providing abortion care and other
gynaecological services while preparing the tools of data collection.
c) Administering the various tools of data collection. Understanding the questions and its
relevance was fundamental to scientifically sound administering of the tools. We also
role-played this among ourselves simulating various field situations. This exercise was
found to be very educative for both, senior and junior researchers. An elaborate
protocol (Annexure 5) to be followed while administering was also prepared.
We could establish rapport with the members of the medical fraternity during the
enumeration phase. Once we would finish the enumeration in particular taluka, we
selected the sample units after discussing among ourselves the entire set of abortion care
facilities to know their profiles vis-a-vis various characteristics.
Locally, members of the medical fraternity became aware of our research within no time.
At times, the providers who exhibited scepticism in the first visit or contact on telephone
showed faith in us during the subsequent interactions. This happened as they would
confirm with their friends about the study and consequences of their own participation in
the study. At two places, the local associations of medical professionals were quite active.
We were invited to share our views with them on abortion issue. We even presented a
paper in one of seminars organsied by one of them for doctors. This helped us establish
rapport and strengthen our ties with the community. In fact, we hardly experienced any
antagonism during the field work. In fact, cooperation and response of even NR-ACF was
quite overwhelming.
The team of the field researchers lived in the closest township. They then would fix up
appointments with the concerned HI and/or APs. At times respondents were anxious to
know as to why were they selected and not the others from the same village/place.
However, our explanation about the concerns for variation in the sample made them feel
comfortable. We did not come across any denials from His to participate in the
quantitative survey. A detailed letter of introduction to the organisation and the research
was given to the respondents. It also explained the thrust of the research, significance of
their participation in the study. It assured them of the confidentiality of the information
obtained from them and of their identities. (Annex 6). We during our introductory
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communication with them emphasised the fact that they had right to withdraw their
participation at any point of time.
In case of the public ACFs included in the sample, we upon the request from the
concerned officials at respective centres, had to seek a written permission from the district
health officer allowing participation of former in the study.
The appointments with HIs/APs for interviewes were generally during their off hours, like
afternoons. Researchers either went alone or in pairs for interviews. It mostly depended
upon the logistics, the need for time optimisation, and need for the researchers themselves.
If in pairs, one person while engaged the respondent by interviewing, the other one
recorded physical standards using observation guide with the help of other staff at the
health care facility. On average, it took about an hour and a half. Privacy during the
interview with HI/AP by and large was not a problem. However, we found it difficult at
times to maintain it with women respondents when their husbands, too were in the medical
profession and were running the set up together. The sensitive areas for them, as we
perceived, were questions about MTP registration status. And there was also a sort of
anxiety the husbands felt that their wives would disclose something to us which was not
supposed to be. But in general, the respondents were at ease while going through these
lengthy interviews.
The institutions where HI was also an AP, we interviewed the respondent for both the
roles. For additional providers other than HI at ACF, we interviewed them separately.
There were multiple providers providing their services at a particular ACF. Often HI were
also providers and engaged themselves in providing service support to ACFs other than
his/her own. We interviewed an individual provider only once regardless of number of
ACFs he/she is providing his/her services for.
The schedules for EH and AP contained some common sections, such as, perception about
women’s abortion needs. In case, a respondent was both, HI and AP, these common
sections were administered only once. As regards the section on role of providers’ as
gatekeepers, we assumed that such a role could be played by either of them or by both.
This section therefore was administered accordingly.
Some ground workfor the qualitative phase, the second phase of data collection was also
done in terms of introducing them with the idea of the this subsequent phase. .
As a token of our gratitude for their cooperation, participation and sharing their views
with us on this socially relevant research, the institutions were presented with a set of our
educational material in local language (Marathi) on abortion for the benefits of the clients
availing these facilities.
3.2 Qualitative case studies
Survey methodologies are inadequate to assess ‘process’ and ‘outcome’ components of
QAC, given the complexities involved in. We, therefore, decided to undertake in-depth
qualitative study of a sub-sample of 23 ACFs . ‘Process’ was assessed primarily by
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observing pre-abortion and post-abortion woman-provider interactions, both from medical
and non-medical point of view.
Selection of the ACFs
The selection was once again purposive. We ensured that ACFs from the three analytical
categories are adequately represented. In addition, qualification of the providers was
considered as one of important variables for inclusion of a particular ACF. (Table 2..7 (a),
(b)). Whether the head of the institution would be willing to participate in in-depth study
was one of the major considerations for obvious reasons. Of the 24 selected for this phase,
there was one drop out. He withdrew because he perceived that our intervention of such a
nature would affect his practice, which they were trying to establish newly.
We, detailed this phase of study to the heads of the institutions during the quantitative
survey. Field researchers used their own discretion and were selective while doing so. This
formed the domain of the units from which we could select the units to be included in the
qualitative phase We allowed this strategy to be used. This is because over and above the
willingness of the HI to participate in the study, it was necessary for us to get to see at
least some women seeking abortion care and that HI allowed us to sit through their
centres and consulting and move around freely. Any restrictions on these would affect the
quality of data collected.
There was a mixed response to this request of ours seeking their participation. This was
anticipated given the intrusive nature of the proposed methodology. We explained to them
its relevance as transparently as possible. Those who were exposed to such kind of work
appreciated fully well the significance of their contribution to the study and agreed almost
immediately to participate in the qualitative case studies. It was an encouraging
experience. However, some others looked at us more as ‘investigators’, investigating into
their “rights & wrongs” rather than as researchers. This, in certain other cases was
combined with a feeling of insecurity, which they themselves attributed either to ‘their
dwindling practice’ or to ‘the phase of establishing their own practice’. They perceived
that our presence at the institution for three days and communication with women clients
on such issue might put the latter off affecting their practice negatively in the future.
However, once again, as was experienced during the quantitative survey, the registration
status of the institution did not matter for those who consented to participate in the
qualitative case studies.
Women clients
We aimed at interviewing minimum one abortion client at each centre. Woman’s
willingness to participate in such a research was the prerequisite. The team of the two
field researchers spent minimum three days at each of the selected ACFs. During our stay
at 23 study units, we could interact with 40 women who came seeking abortion care
services. Of these 10 did not undergo abortion and therefore could only be studied for pre
abortion care. The rest 30 were observed for various aspects both, pre and post abortion
care services.
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Tools of data collection
A combination of tools was used in this phase of data collection. We designed an
observation guide, which was complemented by in-depth interview guide for women who
utilised abortion care services. (Annexure 3(a) & (b)). A record sheet for analysing case
papers to study the biomedical aspects of‘outcome’ was also designed. (Annexure 3 (c) &
(d)). Content of these tools of data collection were largely guided by (a) content of the
‘process’ and ‘outcome’ indicators of QAC as laid down the model and (b) by our field
experiences and trends observed in the data obtained during the quantitative survey.
Observation Guide for observing pre and post operative interactions between provider
and client and between the other staff and the client. Consulting room, wards/rooms
where the clients were admitted were the sites for these observations. We documented the
interactions mostly on the spot, as extensively as possible.
Interview Guide for women clients to respond to who have undergone abortions and
those who have come for post abortion complications.
Condiict of the qualitative phase
We conducted qualitative case studies two months after the quantitative survey was over.
These were used mainly used to get some data trends before we launched the second
phase. We sent out detailed letters to the respondents and scheduled the field visits in
consulation with them. They were responsive and co-operative. We communicated them
the need to seek woman’s informed consent before we included her in the study. This was
appreciated and respected. However, it was difficult to operationalise. This was the most
significant and difficult part of the qualitative study. The process remained rather
unstructured. Many a times, HI or AP had done this on our behalf. While we
acknowledged the implications of HI or AP seeking a consent of women, we had less
choice and less control over the situation. Women, too felt more comfortable with the
staff of the institution, at least, for initial interactions. The researchers were introduced to
women at appropriate time by the medical staff. From that point onwards, we built
communication with women. We preferred to communicate the study to women verbally
and therefore did not have anything in writing about the study. This obviously implied
variation in the style and the flow of communication as researchers used their own
discretion to decide upon these aspects keeping woman’s comfort at the centre. Women’s
right, and for that matter even of the heads of the institutions, to withdraw from the study
at any point of time, was regarded of the utmost importance. Generally, women talked to
us. However, we would hesitate to consider them as enthusiastic responses. The physical
and mental strain and stress that they were bearing was more than obvious. The setting of
medical care institutions provided us less scope for better means of rapport establishment.
Interviewing women in this setting had both advantages and disadvantages. It was
advantageous for there were less chances of we missing out on some information.
However, the presence of the staff around them, which was beyond our control, seemed to
have constrained their openness while responding.
In the entire phase of data collection, the most vulnerable situations the researchers found
themselves in were those of collecting information from women as we could empathise
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with their mental state of mind. We did find ourselves ‘investigative’ and ‘interrogative’
then and almost did not want to interview women.
We could not complete interviews with two women. In case of one of them, the field
researcher felt that she was scared of her husband for letting such views out about the
health care facility in general or the medical staff in particular. Our communication with
her was perceived by her husband to be affecting their relationship with the institutions. It
was more of our decision not to continue with her than her withdrawal. The other woman
did not want to interact with us at all or for that matter with anyone around her. The field
researcher came to know that she has had two consecutive abortions of 4-5 months of
gestation in the near past and was kind of feeling helpless for not being able to tackle it.
She perhaps had developed some inferiority complex. It was not very difficult for us to
understand and empathise with her state of mind. The field researcher neither wanted to
encroach on her privacy nor wanted to hurt her feelings. We did not go ahead with it,
respecting her decision of not participating in the study.
The data were either documented on the spot or the short-notes were expanded later on
the same day depending upon the situation.
4. DATA ANALYSIS AND PRESENTATION
Registration status, location (rural/urban) and type of the sector (private/public) of the
health care facilities are the three basic analytical categories used in the report.
Quantitative data were analysed using SPSS (Windows version).
The data obtained from the quantitative survey are mainly used to understand physical
standards. We relied mostly upon simple frequency tables and contingency tables. At
times composite analysis is used, especially while dealing with the data on ‘structure’. The
explanatory notes will be found in the report when required.
Data obtained on perception of His and APs about women’s abortion needs etc. in the
quantitative survey were used in the form of narratives to construct the arguments
followed by discussion. The responses to open ended questions were structured and
quantified to be used.
The data obtained through qualitative case studies, are mostly used to present the various
live situations that we witnessed with the least possible of contamination arising from
intermingling the data and their interpretations. We presented situations, which are
followed by our commentary and/or discussion. However, the subjectivity that arises
because of researcher’s point of view and overall ideology/position on a particular issue
while presenting such situations is implied and inevitable. The presentation of the data
follows themes picked up from the QAC model. Not all cases could provide us data on all
aspects of quality of care that were being studied during the qualitative phase of the study.
Selecting a particular situation (a case or part of the case) for a particular theme was
mainly guided by the quality of the data. We also tried to quantify some of the information
obtained through qualitative case studies, such as, diagnostics conducted, information
given and obtained.
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5. PROBLEMS ENCOUNTERED
A number of problems were encountered during the conduct of the entire project,
specially during the phase of designing the methodology and conducting the field work on
account of poorly maintained data in the government offices. A few are listed here, (a)
The government records about registered MTP centres were poorly maintained, and there
was under reporting and/or non-existence of records of MTPs done at these centres, (b)
There were discrepancies in official records kept by different offices about the public
HCFs engaged in abortion care services, (e) They were no data available on health care
facilities, which could be used to draw our sample for the study. Researchers, in the past,
often faced problems of defining the universe in any such study because of high percentage
of unregistered nursing homes and poorly maintained records of health care facilities and
providers by both, the government and Medical Associations. We were no exception.
We found difficulties in obtaining data on case papers, records, consent form, doctors’
approval form etc. They generally were not systematically maintained. Besides, one
particular document was used for more than one purpose. For instance, often there was no
separate consent form maintained for woman undergoing abortion. Often case paper was
additionally used either as woman’s consent form and/or as doctor’s approval form.
Similarly, we found that heads of the institution found it difficult to respond to a querry
on number of beds for O/G etc.
6. METHODOLOGICAL AND ETHICAL ISSUES
Primarily we faced problems as regards operationalisation of the indicators of QAC,
measurement of the indicators and choosing the appropriate methodology/tool of data
collection. Not able to quantify or measure the indicators in a tangible manner, not able to
completely control subjectivity (observational tools of data collection), not able to control
the impact of confounding factors, not able to completely address the ethical issues
involved etc. were the areas of concern.
Some of the problems could be taken care of by refining the tools of data collection.
However, at times, tools of data collection and methodologies themselves have inherent
limitations, which can hardly be helped. We chose them despite these limitations because
they are less intrusive and are more sound ethically and otherwise, than the others. For
instance, direct observation of client-provider interactions was preferred over the other
methods such as simulated or mystery-client approach. In certain regards, optimisation of
the available resources was the concern in choosing one method over the other. For
example, some data would have come by on bio-medical indicators measuring ‘outcome’,
if women were followed up post abortion for some specific period. Below are the various
issues and concerns that we feel are important to be recorded, shared with and discussed
among the peers.
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Measurement of indicators and choice of methodology
Assessment of 'structure1
Most of the data on ‘structure’ aspect were collected in the quantitative facility survey
using observation guide containing exhaustive checklists. And yet, we were not able to
talk in terms of sufficiency of instruments and range/sizes of a particular instrument. For
instance, not all institutions had the entire range of cannulae or speculum of different sizes.
Also the aspects such as sufficient sunlight, cleanliness, hygienic conditions at the
operation theatre, crowdedness etc. could not be made totally free of individual
researchers’ bias, e of the aspects, such as, availability of filled oxygen cylinders all the
time was difficult to judge.
Assessment of 'process'
We used observation guide to assess provider-client relationship. It helped to assess the
content of communication and the extent of coverage of type of information exchange.
However, aspects such as, assessment of an impact of power relationship between clients
and providers remains intangible. These aspects of communication are more to feel and
sense rather than measure and quantify. As far as methods of data collection are
concerned, there is less scope to improve upon it. However, the methods of data
presentation and analysis can take care of inadequacies of these methods of data collection
to certain extent. For example, narratives and case presentations drawn from observation
data can help understand the impact of these factors and to gather nuanced insights into
situations.
We also decided against an assessment of the technical competence of the abortion care
providers (medical professionals). None of the researchers or field investigators belonged
to medical fraternity. We, therefore, did not feel it ethically justified to assess this
particular aspect. Two, we on ethical grounds decided not to observe the provider-client
interaction during actual examination and abortion procedure regardless of whether the
provider and woman had allowed us to do so. However, the extent of encroachment that
we had to impose both on women and providers was perhaps inevitable in this kind of
research which we have indulged ourselves in.
Aggregating data
Aggregating the results of such observation based data are not possible and thus is the
inherent constraint of this approach. This is necessarily because they are the data drawn
froma sub-sample. Besides, at one particular institution, more than one women were
observed who naturally differed as regards their profile in every sense. These differences
introduced confounding factors. At one particular institution, there were multiple
providers which added another set of confounding factors. In this situation, presenting the
detailed narratives describing the context of a particular client-provider interaction is more
insightful despite its constraints as regards aggregating and quantification of data.
Ch II
Study Design and Methodology
45
Waiting period was difficult to assess objectively. It generally is a function of the qunatum
of the clients at a particular HCF and of the time the provider spends with his/her clients.
More waiting period for a woman may mean more time a provider spends with an
individual client. It was therefore difficult to assess it objectively.
The extent ofhawthorne effect
The presence of researcher that would change the behaviour of those being studied in
positive direction is known as hawthome effect. In the present we found that the
respondents were quite ‘their own souls’ despite our presence. At times, the respondents
perceived that we were there to gauge the immorality that exists out there in the society
and to which they were the witness. In that, we were considered as their allies rather than
researchers assessing the quality of care that they were providing. This is because the
quality of care that the women seeking abortion care received, as the data reveal in the
report, is found to be unacceptably poor. Thus, even if we assume that our presence
affected the behaviour of providers positively, one can only imagine as to how worse off
the situation must otherwise be.
Assessment of 'outcome ’
Data on biomedical outcome were difficult to come by in the present study as we did not
follow-up women post abortion to know if they had any post abortion complications. The
other option was to identify and interview women who have undergone abortion at these
health care facilities in last three/six months to trace the post abortion complications, if
any. This is generally referred to as case finding method. We consciously avoided this as
we did want to get into the communities where women live as ‘confidentiality’ of
abortion would be their prime concern.
We used post-operative interviews, quite similar to the technique of exit interviews for
eliciting women’s responses about their (dis)satisfaction vis-a-vis abortion care responses.
This method has an edge over the conventional exit interviews in the present context as
the researchers and the women respondents had by then interacted enough at least to
break barriers arising of being strangers to each others. However, the known limitations
of exit interviews, such as courtesy bias, unwillingness to speak after an operative
procedure couldn’t be completely eliminated. In fact, courtesy bias in abortion care may
be more compared to other healthi care seeking situations for obvious reasons. Measuring
magnitude of these biases is difficult.
The record sheet as a tool for analysisng the case papers and related documents to study
post abortion complications did not fetch us any meaningful data for record maintenance
at ACFs was poor.
Ch II
Study Design and Methodology
46
Table 2.1 : District-wise relative index of development and percentage of urbanisation
DISTRICTS
RELATIVE INDEX OF
DEVELOPMENT*
704
_____________ 157
_____________ 128
_____________ 109
_____________ 104
______________ 99
______________ 88
______________ 87
______________ 85
______________ 85
______________ 85
______________ 83
______________ 81
______________ 79
______________ 74
______________ 73
______________ 72
______________ 72
______________ 68
______________ 67
______________ 65
______________ 65
______________ 64
______________ 62
______________ 59
______________ 55
______________ 53
______________ 51
51
DISTRICTS
URBANISATION
(%)**
100.00
64,64
61.78
50.74
35,55
32,76
32.60
28.77
28.65
28,04
27,44
26,56
26,33
22,74
22,51
21,72
20,59
20,50
20,39
18.01
17,94
16.91
15.82
15.19
13,09
12,88
_______ 8.94______
_______ 8,71_______
7.59
Mumbai
Mumbai
Pune_______
Thane______
Thane______
Nagpur
Nagpur_____
Pune_______
Kolhapur
Nashik_____
Wardha
Aurangabad
Raigarh
Amravati
Sangli______
Solapur
Solapur
Akola______
Aurangabad
Chandrapur
Jalgaon_____
Jalgaon
Satara______
Wardha
Nashik_____
Kolhapur
Ahmadnagar
Sangli______
Amravati
Parbahani
Bhandara
Nanded
Dhule______
Buldhana
Chandrapur
Dhule______
Sindhudurg
Latur_______
Parbahani
Raigarh
Akola______
Beed_______
Jalna______ _
Jalna_______
Gadchiroli
Ahmadnagar
Osmanabad
Osmanabad
Buldhana
Bhandara
Beed_______
Satara______
Nanded_____
Ratnagiri
Latur_______
Gadchiroli
Ratnagiri
Sindhudurg
Maharashtra
Maharashtra
state_______
state
* Source - ‘Economic Intelligence Service’, Published by Centre for Monitoring Indian
Economy Pvt. Ltd., November 1993
The weightage pattern adopted to develop Relative Index of Development is as follows :
1. Agricultural sector — 35% (per capita value of output of crops - 25% + per capita
bank credit to agriculture -10%)
2. Mining & manufacturing sector — 25%
( Mining, manufacturing non-household & household workers per lakh of population-15%
Per capita bank credit to industry — 10%)
3. Service sector — 40% (Per capita bank deposit -15% + per capita bank credit to
services -15% + literacy - 4% + urbanisation - 6%)
** Source - ‘Economic Intelligence Service’, Published by Centre for Monitoring Indian Economy Pvt.
Ltd., November 1993.
Ch II
Study Design and Methodology
48
Table 2.2 : MTP facilities in the private and public sector
Sr No Talukas in
Pune district
Number of institutions
providing abortion care
facilities
Sr No
Talukas in
Ratnagiri district
Number of institutions
providing abortion care
facilities
Private
Public
Private
Public
(PHC + RH+ Civil/
(PHC + RH+ Civil/
district)
_______ district)
1
Ambegaon
3
1 of6 + l
2/-+ 2 + 0
Chiplun_____
3
2
Baramati
Nil
1 of8 + l + 1
2_
Dapoli______
1
- +1+0
3
Bhor_____
1
3 of 5 + 1
Guhaghar
Nil
0+0+0________
2
4
Daund
1
1 of 5 + 1
£
Khed_______
3
0+0+0________
5
Haveli
18
1 of 10 + 0
5
Lanja_______
Nil
1/-+1+0_______
6
Indapur
Nil
4of8 + 2
Mandangad
1
0/-+1+0_______
7
Junnar
1
2 of 10+1
£
Rajapur_____
Nil
1/- + 2 +0
8
Khed
3
4 of 10+ 1
£
Ratnagiri
8
2/- +0+1
9
Mawal
4
1 of 7+ 1
9
Sangameshwar
2
10
Mulshi
Nil
1 of 5 + 0_____
11
Purandar
1
1 of 5 + 1
12
Shirur
Nil
1 of 7 + 1
13
Welhe
Nil
1 of 2+ 1
Total
32
22 of
18
88+12+1_______________________
Source : MTP cell, DHS, Mumbai, Maharashtra; Zilla Parishad, Pune; Civil Hospital, Ratnagiri.
Ch II
Study Design and Methodology
49
Table 2.3(a) Ranking of teshsils in Pune district on sex ratio and proportion urbanisation
Sr no
Tahsil
Sex ratio
Rank
Sr no
Tahsil
1
2
Bhor
Velhe
Ambegaon
Junnar
Purandar
Mulshi
Shirur
Khed
Baramati
Daund
Indapur
Mawal
Pune city
Haveli
1038
1044
1002
1002
989
972
1
2
1
2
3
4
5
3
6
6
7
8
9
10
11
12
13
14
7
8
9
10
11
12
13
14
Pune city
Haveli
Mawal
Purandar
Baramati
Indapur
Daund
Bhor
Shirur
Junnar
Khed
Velhe
Mulshi
Ambegaon
3
4
5
6
7
8
9
10
11
12
13
14
969
960
940
933
931
926
919
882
4
5
Proportion
Urban
99,54
66.45
38,78
18.91
14.34
13.74
12.63
9,73
7,69
7.05
3.62
Rank
1
2
3
4
5
6
7
8
9
10
11
Table 2.3(b) Ranking of teshsils in Ratnagiri district on sex ratio and proportion urbanisation
Sr no
2
2
5_
2
2
2
9
Tahsil
Guhaghar
Mandangad
Rajapur
Dapoli
Sangameshwar
Lanja
Khed
Chiptuu
Ratnagiri
Ch IJ
Study Design and Methodology
Sex
ratio
1,355
1,280
1,277
1,264
1,231
1,227
1,175
1,125
1,107
Rank
Sr no
Tahsil
2
2
2
2
2
2
2
2
2
2
2
9
9
Ratnagiri
Chiplun
Dapoli
Khed
Rajapur
Mandangad
Guhaghar
Lanja
Sangameshwar
±
2
2
2
2
Proportion
Urban
22.47
15.39
12.34
6.20
5.47
Rank
2
2
2
2
5
50
Table 2.4(a) Universe and sample
District
Tahsil
Characteristics of the HCF
Public
Pune
Baramati
Ambegaon/
Junnar
Sub-total
Ratnagiri
Ratnagiri/
Chiplun_____
Manadangad
Rajapur/Khed/
Guhaghar
Sub-total
Total
Private
Proposed sample
10
5
Universe
5
6
Sample
5
4
Proposed sample
10
10
Registered
Universe
0
8
15
11
9-
20
7
6
20
83
47
3
3
3
10
13
13
10
21
16
2
4
4
10
4
4
10
13
13
5
20
7
18
7
16
20
40
17
24
17
23
20
40
34
117
29
76
Table 2.4 (b) Percentage coverage in the sample
Characteristics of HCF
________ Urban_______
________ Rural________
________ Public_______
_______ Private_______
Registered
Non-registered
Total
Ch II
Study Design and Methodology
Sample & % coverage
71 (71.0)
44 (74.6)
16 (88.9)
Universe
100(100)
59 (100)
18 (100)
23 (95.8)
76 (65.0)
115 (72.3)
24 100.0)
117(100.0)
159 (100.0)
Table 2.4(c)
Sample
0
6
______________Non-registered
Proposed sample
Universe
10
33
10
50
Sample
28
19
Comparison of Proportionate Representation of
various categories in the universe and sample
Characteristics of HCF
________ Urban________
________ Rural________
________ Public________
_______ Private_______
Registered
Non-registered
Total
Sample & % coverage
71 (61.7)
44 (38.3)
16(13.9)
Universe
100 (62.9)
59 (37.1)
18(11.3)
23 (20.0)
76 (66.1)
115 (100.0)
24 (15.1)
117(73.6)
159 (100.)
51
Table 2.5: Profile of the HCF and ACFs surveyed during enumeration
No ofHCFs
Characteristics of the health
care facilities surveyed
Districts ________________
301
Pune______________________
223
Ratnagiri__________________
Tahsil____________________
174
Baramati__________________
43
Ambegaon_________________
84
Junnar____________________
71
Ratnagiri__________________
56
Chiplun___________________
19
Mandangad________________
40
Rajapur____________ _______
17
Guhagar___________________
20
Khed_____________________
Rural/Urban_______________
299
Urban_____________________
225
Rural
__________________
Public/private______________
38
' Public_____________________
486
Private____________________
Institutions providing abortion care
365
No___________________________
159
Yes___________________________
MTP Registration status_____
42
Registered_____________________
117
Non-Registered_________________
365
Don't provide abn care____________
Total
Total No of ACFs
(universe)
No of ACFs
In the sample
102
57
62
53
38
24
40
21
15
4
3
5
9
33
11
18
19
13
4
3
5
9
100
59
71
44
18
141
16
99
159
115
42
117
39
76
its
159
V* ,'T
Ch II
Stydy Design and Methodology
y P»i
v
07852
as
A
A' z/
Table 2.6(a) Gaps between government information sources and the preparatory survey as
regards MTP care facilities
Selected tehsils
in the selected
Districts
Number of MTP facilties in
!
Public
Private
According to
!
!
According to
Government ! Preparatory ! Included in ! Government ! Preparatory
survey
sources
!
! the sample !
survey
sources !
6
11
4
8*
11
7
7
15
16**
£
Pune
Ratnagiri
!
! Included in
the sample
6***
17****
*
Of these, 4 were found to be claiming MTP registration status. However, during the second
phase, during our interactions with them at length, it was found that they were not registered
**
***
****
Two got their MTP registration cleared during our field work period
One got its MTP registration cleared during our field work period
Table 2.6(b) MTP facilities at the public health centres - infn from govt records, first hand infn
and the inclusion in the sample
Sr No
Taluka
1.
Ambegaon
2.
Junnar
Number of public health care facilities providing MTP care facilities
According to govt sources
According field sources
PHC + RH + Civil/Distirct/
(preparatory phase)
_________ municipal
0
+ 1+0
1 +
1+0
Ghodegaon
Dhamani Ghodegaon
Included in the
sample
0+1+0
1
+ 1 +0
Otur Narayangaon
2 +
2(RH Narayangaon
1+ 2
Belhe & cottage at Junnar)
(RH+cottage)
Otur
Otur_________
3.
Baramati
1
+1+1
l(PHS) +2
+1+1
l(PHS)+2+l+l
Pandere Supa Baramati
Jalgaon Pandere Supa Bara
Pathare Lonibhapkar_______
4.
Ratnagiri
2
+ 0
+ 1
1
+0
+1
1+0+1
Pawas
Ratnagiri Kotwade
Ratnagiri town
Kotawade
5.
Chiplun
2 +
2+0
0+1 (RH Kamthe)+0
0+1 (Cottage) +0
Rampur
Chiplun (cott)
Dadara
Kanithe (RH)
6.
0
Mandangad
+ 1
+0
0+l(Manddangad) +0
0+1+0
Mandangad
7.
Rajapur
1
+2+0
0+1 (Rajapur) +0
0+1+0
Jaitpur Rajapur
Raipatan
8.
Guhaghar
0
+0+0
0+1 (Guhaghar) +0
0+1+0___________
9.
Khed
0
+0+0__________________________________________________________
0+0+1 (Khed)
0+0+1 (Municipal)
Note : Except two, we included all the public health care facilities providing MTP services that we visited in
the preparatory survey. One (Dhamani PHC) from Ambegaon and one (Yenere PHC) from Junnar are the
ones not included. At the former, the MO had not yet started providing abortion care and at the latter, we
could not meet the MO and thus interviews could not be conducted.
Ch II
Study Design and Methodology
53
Table 2.7(a) Profile of the health care institutions
included for case studies
Characteristics of the
health care facilities
______ surveyed_____
Districts____________
Pune_______________
Ratnagiri____________
Tahsil______________
Baramati____________
Ambegaon___________
Junnar______________
Ratnagiri____________
Chiplun_____________
Mandangad__________
Rajapur_____________
Guhagar____________
Khed_______________
Rural/Urban________
Urban______________
Rural_______________
Type of institution
Public______________
Private______________
Structure of the
institution___________
Maternity Hospital
General Hospital______
Registration status
Registered___________
Non-registered________
Qualification (HI)
Gyneac (DGOs & MPs)
Allopath + MTP trg
Other non-gyneac
allopaths____________
Non-allopaths________
N=23
No of health care
facilities
9
14
4
2
3_
6
1
2
16
7
4
19
8
15
11
12
11
5
3
4
Table 2.7(b) Distribution of the private ACFs over rural and urban in the study
area according to their registration status
Districts
Urban
3 (75,0)
Rural
Public
1 (25,0)
Total
4(17,4)
Private
________ Regtrd
_____ Non-regrd
Total
6 (85.7)
7(58,3)
16 (69.6)
1 (14.3)
5 (41,6)
7 (30.4)
7 (30,4)
12 (52,2)
23 (100.0)
Ch II
Study Design and Methodology
54
pJjStUP^. 2
MAP OF THE STUDY AREA
INDIA
Maharasbi
Pune
Rataagiri
Underdeveloped Area
Developed Area
MANDANGAD
JUNNER
KIIED
GUHAG.
’LUN
AMBEGAON
yRAT^AGIRI
1
PUNE
RATN/
/
KAJAPlJ
2
FIGURE 2(a)
SPATIAL DISTRIBUTION OF ABORTION CARE FACILITIES (ACFs)
IN SELECTED TEHSILS OF PUNE DISTRICT
LEGEND
'nne:
Higher Proportion Urban
Lower Proportion Urban
i''-'
Public ACF
O Private ACFs
AMB
AON
‘■QA
'b
a
A
1
OA
10
A-
A
BARAMATI
o
6
'o2
BARAMATI
Code
Village
-22+1
1.
-1 + 1
2.
Ambegaon(TP)
Manchar
Dhamani
Loni
Awasari (K)
Awasari (B)
ACF
Code Village
Pvt. - Public
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Baramati (TP)
Supe
Morcgaon
Katewadi
Sangavi
Jalgaon K.P.
V. Nimbalkar
Malegaon B
Pan dare
Loni-Bhapkar
Sortewadi
JUNNAR
AMBEGAON
3.
- 1+0
4.
5.
-
Code
Village
6+ 1
1.
10 + 0
0+ 1
4+0
1+0
1 +0
2.
3.
4.
5.
Junnar(TP)
Narayangaon
Otur
Belhe
Alephata
Pimpalwandi
Pvt. - Public.
- 3+0
- 1 +0
-0+1
ACF
6.
ACF
Pvt.- Public
6.
8+ 1
14+ 1
4+1
4+0
5+0
2+ 0
2+0
1 +0
0+1
0+1
2+0
38
Denotes One Public Centre
24
40
FIGURE 2(b)
SPATIAL DISTRIBUTION OF ABORTION CARE FACILITIES
(ACFs) IN SELECTED TEHSILS OF RATNAGIRI DISTRICT
MANDANGAD
LEGEND
| Higher Proportion Urban
|
Lower Proportion Urban
;:j
KHED
Public ACF
Private ACFs
2^
O
GUHAG
CHIPLUN
h
RATNAGIRI .
O
J.
/
\
fl
ZX-
, ' X - X x SX ' ' X y' ■
RAJAPUR
VILLAGE
CODE
_______ ACF CODE VILLAGE
T. P.
Pali
Nivali
Jakadevi (Khalgaon)
Pawas
Khandala (Watad)
Nachane
14 + 1
1+0
1 +0
1 +0
0+ 1
1 +0
1 +0
1.
2.
3.
4.
5.
T. P.
Akhale
M. Tamhane
Dervan
Kamthe
—71
1.
2.
VILLAGE
T.P.
Panderi
CODE
VILLAGE
10+0
1 + 0
2 + 0
1 + 0
0 + 1
1.
2.
3.
T. P.
Nara van
Welamb
ACF
2ODE
Pvt.+ Public
1.
2 + 1
1 + 0
2.
3.
4
Z\ Denotes One Public Centre
VILLAGE
RAJAPUR
ACF
CODE
VILLAGE
Pvt. + Public
T. P.
Lavel (D)
Lote
ACF
Pvt. + Public
2 + 1
1 + 0
1 + 0
5
15
KHED
MANDANGAD
CODE
ACF
Pvt,+ Public
Pvt.+Public
1.
2.
3.
4.
5.
6.
7.
GUHAGAR
CHIPLUN
RATNAGIRI
6 + 1
1 + 0
1 + 0
9
1.
T. P.
ACF
Pvt. + Public
2 + 1
3
Chapter III
ACCESS TO ABORTION CARE SERVICES:
AVAILABILITY, APPROACHABILITY & AFFORDABILITY
1. Availability of abortion care services
1.1 Share of abortion care facilities
1.2 Contribution of the public health care facilities
1.3 Contribution of the private health care facilities
1.4 Distribution pattern of abortion care facilities
1.5 Adequacy of abortion care facilities
2. Approachability to abortion care services
2.1 Spatial spread of the abortion care facilities
2.2 Approach road, mode of transport and time taken
3. Affordability/cost of abortion care
3.1 Cost of travel
3.2 Cost of medical care
4. Summary & Conclusions
The data presented in this chapter are organised under three sections. They are (1)
Availability of abortion care services. (2) Approachability to abortion care services.
(3) Affordability /cost of abortion care. Analysis is carried across districts to explore if
development status of a district has any association with access to abortion care services.
Availability of abortion care facilities has been assessed by analysing the data obtained
from 524 HCF that constituted the entire health care service sector except the
specialised ones and 159 ACFs from among these, which constituted the entire
abortion care services in the study area. These data have been contextualised by using
secondary data on availability of MTP services at national and Maharashtra state level,
when required and possible. An asessment of approachability to and affordability of
abortion care cost is made using the data obtained from 40 women who came to our sub
sample of abortion care facilities.
1. AVAILABILITY OF ABORTION CARE SERVICES
Availability of abortion care services is studied by examining the proportion of HCFs that
was engaged in provision of abortion care services in the study area; the extent of
contribution of the public and private HCFs to abortion care services. The distribution of
ACFs over urban/rural; public/private is examined. Further, adequacy of abortion care
facilities to meet women’s abortion needs is also estimated.
Chin
Access to abortion care: Availability and approachability, affordability.
55
1.1 Share of abortion care facilities1
The extent of share of HCFs in abortion care service provision, in general, would suggest
the scope for expansion of abortion care facilities at the available HCFs. Only about 30.3
per cent (159 of 524) of the health care facilities were engaged in abortion care services
suggesting a wide scope for expansion of abortion care services (Table 3.1). This is better
than the national level figures which is 23.2 per cent according to 1997 data. Better share
of abortion care services in the total health care facilities available in Pune district
compared to Ratnagiri (about one third and one fourth respectively) indicates that
development status may have association with the extent of availability of abortion care
services.
Similarly urban areas seemed to be better placed as proportion of the urban based HCFs
enganged in abortion services is more than that of rural based ones.
Table 3.1 Proportion of ACFs to the total HCFs in the study area
District
Characteristics of
HCFs
Whether provides abortion care services
Yes
Pune
Urban
Rural
Sub total
Ratnagiri
Urban
Rural
65 (36,5)
37 (30.1)
102 (33.9)
35 (28,9)
22 (21,6)
Sub total
57 (25.6)
Grand total
159 (3030)
Total
No
113(63,5)
199 (66.1)
178 (100,0)
123 (100.0)
301 (100.0)
86 (71.0)
80 (78,4)
166 (74.4)
121 (100,0)
102 (100,0)
223 (100.0)
86 (69.9)
365 (69.7) | 524 (100.0) |
1.1.1 Contribution of the public health care facilities
All PHCs, RHs, CHs, distirct hospitals and civil hospitals along with all the post partum
and family welfare centres are eligible for providing abortion care provided they meet the
minimum physical standards stipulated in the MTP Act and are equipped with qualified
abortion care service provider as stated in the Act. Information was collected on all the
public HCFs eligible for providing abortion care and on which of them are providing
abortion care services in the nine tehsils under study to better understand the
proportionate share of public HCFs in abortion service provision.
Only about 24.7 per cent of the total eligible public HCFs in the study area are engaged in
abortion care services. (Table 3.2). This is about three times more than the national level
statistics which shows that it was only about 8 per cent according to the data available for
year 1994. This wide gap between macro and micro level data must reflect the skewed
1 The share of health care facilities in abortion care service provision could be studied as all the
health care facilities (except specialised health care services) were surveyed in the study area
Chin
56
Access to abortion care: Availability and approachability, affordability.
distribution ofpublic ACFs across the regions and states. The percentage proportion of
the public ACFs in case of Pune district is about three times larger than that of Ratnagiri
district. Across tehsils, the percentage proportion of the eligible public HCFs engaged in
abortion care service provision ranges between 9.1 per cent to 55.6 per cent. Within
districts, there is variation across tehsils, too. In Pune district it is at least about one third
whereas in Ratnagiri it is at the most is about one third. This reflects on the fact that the
skewed contribution pattern prevails even over smaller geographical areas.
The differentials in contribution of public HCFs in abortion care service provision across
Pune and Ratnagiri districts is also a pointer towards a probable positive association
between development status of the areas/districts and the contribution ofpublic health
care facilities to abortionr care services. However, it can’t be generalised for obvious
reasons.
With regard to general health care (or overall health care sector), private sector’s
contribution is about 70 per cent (Duggal, 1996; Jesani, 1994). In the study area,
contribution of the private sector shoots up to the level of 87 per cent of the total health
care service provision leaving only 13 per cent to be served by the public health care
services2. Against this reality, the contribution of the public HCFs in abortion care service
provision of the magnitude of about less than a quarter alarmingly magnifies its poor
contribution. It, therefore, also is a pointer to the fact that a very large number ofpublic
HCFs are not equipped to meet women specific health care needs in general.
The low contribution of public HCFs to abortion care services suggests that there is a
considerable scope for expansion of MTP services within the public sector. Based on our
field experiences and some of the earlier research one of the immediate measures to
achieve this is to optimise the existing resources. In that, efforts to coincide appointment
of skilled personnels/ doctors in MTP care with infrastructurally equipped HCF for MTP
would certainly enhance physical availability to quite some extent without really
increasing budgetary allocations per se for MTP services, an often stated constraints by
the government.
Table 3.2 Abortion care services: Contribution of the public health care facilities in
the study area*
District
Pune
Tahsil
Baramati
Ambegaon
Junnar
Sub-total
Public HCFs
engaged in
abortion care
services
5
2
4
11
Total
public
HCFs*
Proportionate share of
public HCFs engaged in
abortion care services (%)
*
9
_____ 6
____ 10
25
55,6
33,3
40.0
44.0
2
In the study area, in an exhaustive enumeration of health care facilities, 486 private HCFs were
identified. In addition, 73 public HCFs existed according to the various government sources
totalling the size of the entire health care service provision to 524 HCFs
Ch III
Access to abortion care: Availability and approachability, affordability.
57
Ratnagiri
Ratnagiri
Chiplun
Guhaghar
Khed
Mandanga
d
Rajapur
Sub-total
2
£
1
7
9
11
5
10
3
22.2
9,1
20,0
10,0
33.33
10
10,0
14.6
48
| Total
|
18 i
73
24.7 I
* Includes urban (district and municipal hospitals) and rural (RHs and PHCs) public health care facilities.
** Data are obtained from various government offices.
1.1.2 Contribution of the private health care facilities
Only about 29 per cent of the total private HCFs in the study area were engaged in
abortion care service provision (Table 3.3). There is no national level or other data
available on this aspect for comparison to make. The percentage proportion of the private
ACFs across districts does not show much difference, though it is slightly more in Pune
compared to Ratnagiri district. This trend differs from that observed in case of
proportionate contribution of public ACFs across disctricts. The percentage proportion of
the private ACFs varies to a great extent across tehsils ranging from 10.5 per cent to 56.5
per cent and is similar to that found in case of public ACFs. But, it does not show any
specific pattern indicating association with the level of urbanisation of a particular tehsil.
In fact Baramati tehsil, a more urbanised tehsil compared to other two, exhibits
comparatively a much smaller share of private HCFs in abortion care service provision.
This suggests chances of under reporting of provision of abortion care facilities by heads
of the HCFs. In case of tehsils in Ratnagiri, two of the less urbanised tehsils, Guhaghar
and Khed show comparable percentage proportion of private ACFs to that of the most
urbanised tehsils - Ratnagiri and Chiplun.
Lack of substantial differential in contribution of private HCFs in abortion care service
provision across Pune and Ratnagiri districts could perhaps be explained by
underreporting in Baramati. This provides space to draw a similar inference as was drawn
in case of the public ACFs. That is, the development status of the region or district would
have positive relationship with contribution of the private HCFs in abortion care service
provision.
The fact that only less than one third of the private HCFs are engaged in abortion care
service provision leaves much for its increased role by expanding the scope similar to that
found in case of public health care services. And also indicates alike public health care
service sector, that even the private health service sector is largely ill-equipped to meet
women specific health care needs or at least unwilling to render such services. And this is
an area for exploration.
Chin
Access to abortion care: Availability and approachability, affordability.
58
Table 3.3 Abortion care services: Contribution of the private health care facilities
in the study area
Proportionate share of
private HCFs engaged in
abortion care services
Total
private
HCFs
Baramati
Ambegaon
Junnar
Sub-total
Private HCFs
engaged in
abortion care
services
__________ 33
__________ 22
__________ 36
91
161
39
77
277
20.5
56.4
46.8
32.9
Ratnagiri
Chiplun
Guhaghar
Khed
Mandangad
Rajapur
Sub-total
19
14
4
8
3
2
50
67
54
16
37
16
19
209
28.4
25.9
25.0
21,6
18.8
10.5
23.9
141
486*
29.0
District
Tahsil
Pune
Ratnagiri
Grand______________ total
(%)
* Of tlie 524 HCFs surveyed, 486 were private and 38 were public.
1.2 Distribution pattern of abortion care facilities
Skewed distribution of health care facilities in favour of urban areas and developed regions
has been a persistent problem. Such a skewed distribution in case of MTP services was
also observed in the analysis of the data from the government sources presented in the
introductory chapter. This has consequences for people’s physical access to health care
services in general.
Urban/rural distribution: Little less than 2/3 of the abortion care facilities are urban
based. (Table 3.4(a)). This serves about 9.8 per cent of the total population under the
study area, which lives in urban areas. Consequently, about 1/3 of the abortion care
facilities serve the rest 90.2 per cent population, which is rural based. In general, Pune
and Ratnagiri districts seem to be similar as regards proportion of urban based and rural
based abortion care service facilities to the total abortion care facilities. Within districts,
there is a variation in the proportionate share of urban based and rural based abortion care
facilities. In five of the nine tehsils, proportion of urban based ACFs is about twice or
more than that of rural based ones. This distribution pattern proves an accentuated
skewed distribution of abortion care facilities in favour of urban areas.
Chin
Access to abortion care: Availability and approachability, affordability.
59
Public/private distribution: Public ACFs have a meagre share (11.3%) in the total
provision of abortion care services. (Table 3.4(a)). In general, the two districts are similar
as regards proportionate share of public and private ACFs in the total abortion care
service provision. Public HCFs in the four tehsils (Guhaghar, Mandangad, Khed, Rajapur)
from Ratnagiri district which were selected on the basis of their comparatively less
urbanised status seem to have better share in abortion service delivery compared to such a
share in case of other tehsils with higher level of Urbanisation. It is to be noted that in
general these are smaller tehsils in terms of population. They have comparatively less
number of health care facilities and yet smaller number of abortion care facilities. It
indicates that less number of private practitioners prefer to establish their practice in less
urbanised tahsils.
Earlier we have seen that only less than a quarter of the total eligible public HCFs in the
study area are engaged in abortion care service provision. This together with a meagre
share of the public HCFs in total provision of abortion care service suggests that currently
a large proportion of abortion care needs are being met with only at a price in private
ACFs forgoing their right to free abortion care services. Women compelled to access
abortion care services at private HCFs also imply that they are subjecting themselves to
unregulated and unaccountable abortion care facilities leading to increased chances of
abortion related morbidity and mortality.
MTP Registration status of abortion care service facilities: Availability of registered
MTP care facilities implies that women can access legal abortion care services provided
they live in conditions, which would enable them to do so. There is no data available on
the existing non-registered ACFs though one can have some estimates about proportion of
legal to illegal abortions.
Overall, the proportion of non-registered (including both public and private) to registered
abortion care facilities is about 2.8: 1. (Table 3.4(a)). In general, two districts differ to a
great extent as regards proportionate share of registered abortion care facilities. It is 4.4:1
in case of Pune district and 1.5:1 in case of Ratnagiri district. The range of variation across
the tehsils also varies to a great extent. Within districts, the degree of skewed distribution
varies to a great extent. For instance, it is as high as 6.6:1 in case of Baramati, one of the
more urbanised tehsils of Pune district and as low as 2:1 in case of Rajapur, comparatively
less urbanised tehsil of Ratnagiri district. In general, the proportionate shares of registered
centres in teshsils of Ratnagiri are better compared to those in Pune district. Though
generalisation must not be drawn from such a study, the above pattern suggests to the
least that the 'developed' or 'urbanised' status of a particular area ensures better
legislative compliance and implementation of the Act.
MTP registration status of the private ACFs: Our data show that for every registered
private ACF there exist about 5 non-registered private abortion care facilities (NR-ACFs)
(Table 3.4(b)). This proves unequivocally that abortion care services in private health
care service sector by and large are illegal. In case of Pune, the developed district it is
much more accentuated (about 1:10) and is comparatively less in Ratnagiri district (about
1:2). Absence of a single registered private ACF in Baramati tehsil of Pune district may
explain the extraordinarily alarming ratio of registered to non-registered private ACFs.
Similarly, in rural areas, for every 1 registered private ACF there are about 11 nonCA///
Access to abortion care: Availability and approachability, affordability.
6o
registered private ACFs. In case of urban areas this proportion is about 1:4 (Table 3.4(c)).
Urban areas seem to be better placed on this count compared to rural areas.
An overwhelming large share of NR-ACFs in the total abortion care service provision
indicates that women are exposed to illegal abortion care services which may be unsafe. In
addition it is evident that the momtoring system is almost non-existent and non-functional.
And it also implies that medical fraternity is either less concerned about complying with
egal measures or is ignorant of such matters. Additionally, this also suggests that
prevailing estimates of unsafe and illegal abortions may be far below the actuals having
adverse implications for policy planning and resource allocations.
Chill
Access to abortion care: Availability and approachability, affordability.
61
Table 3.4(a) ACFs by characteristics
District
Number and % of ACFs in
Tahsil
Urban
Pune
Baramati
Ambegaon
Junnar
Sub-total
Ratnagiri
Ratnagiri
Chiplun
Sub-total
Total
Grand
total
Public
Private
Total
Registered
14
36.8
14
58.3
9
22.5
37
36.3
38
100.0
24
100.0
40
100.0
102
100.0
5
13.2
2
8,3
4
10.0
11
10.8
33
86,8
22
91.7
36
90.0
91
89.2
38
100.0
24
100.0
40
100.0
102
100.0
5
13.2
6
25,0
8
20.0
19
18.6
15
71.4
10
66.7
6
28,6
5
33,3
5
100.0
2
22.2
4
100.0
21
100.0
15
100.0
5
100.0
9
100.0
4
100.0
3
100.0
57
100.0
159
100.0
2
9,5
1
6,7
1
20.0
1
11.1
1
25.0
1
33,3
7
12.3
18
11.3
19
90,5
14
93.3
4
80,0
8
88.9
3
75,0
2
66.7
50
87.7
141
88.7
21
100.0
15
100.0
5
100.0
9
100.0
4
100.0
3
100.0
57
100.0
159
100.0
10
47.6
5
33,3
1
20.0
5
55.6
1
25.0
1
33.3
23
40.4
42
26.40
7
77.8
Mandangad
Rajapur
Total
24
63,2
10
41.7
31
77.5
65
63.7
Guhaghar
Klied
Rural
3
100.0
35
61.4
100
62.9
22
38.6
59
37.1
Chill
Access to abortion car services: Availability, approachability & affordability.
NonTotal
registered
33 38 100.0
86.8
18 24 100.0
75.0
32 40 100.0
80,0
102
83
100.0
81.4
11
52.4
10
66,7
4
80.0
4
44.4
3
75,0
2
66,7
34
59.6
117
73.6
21 100.0
15 100.0
5
100.0
9
100.0
4
100.0
3
100.0
57
100.0
159
100.0
6^
Table 3.4(b) Districtwise registration status of private ACFs in the study area
Districts
Pune
Ratnagiri
Total
Private ACFs
Registered
______ 8 ( 8,8)
16 (32.0)
24 (17.0)
Total
Non-registered_____
__________ 83 (91,2)
__________ 34 (68,0)
117 (82.9)
91 (100,0)
50 (100,0)
141 (100.0)
Table 3.4(c) Distribution of the private ACFs over rural and urban in the study
area according to their registration status
Districts
Urban
Rural
Total
Private ACFs
Registered
20 (21,5)
4 (8.3)
24 (17.0)
Non-registered_____
__________ 73 (78.5)
__________ 44(91.7)
117 (82.9)
Total
93 (100.0)
48 (100.0)
141 (100.0)
1.3 Adequacy of abortion health care facilities
Adequacy of the available abortion care facilities is assessed by studying proportion of the women
of reproductive age that abortion health care facilities may have to attend to for their abortion care
needs. Alternatively, number of abortions per abortion care facility, that is the case load of abortion
would also provide such an assessment.
Data show that the number of women per ACF to varied between 172 to 21553. (Table 3.5(a)).
Consequently the case load ranged between 54 to 480 abortion procedure per ACF per annum. This
is much higher than the national level statistics which was 66 MTP procedures per MTP centre.
(Family Welfare Programme in India, Year book, 1993-94).
The extent of the case load would have Implications for other aspects of quality of abortion care,
too. For example, skewed distribution of ACFs would lead to corresponding skewed case load at
ACFs. This means at HCFs with heavier case load, the limited resources, such as, the entire range
of infrastructural facilities and human power, at a particular facility, get shared among the larger
number of clients than what it should serve. Contrary to this, with low caseload at HCFs, the
resources may remain underutilised. If so, service providers’ economics is likely to work against
the interests of users of services. This is because providers would tend to charge more to users to
compensate for underutilisation of their facility. It, therefore, seems that the implications of either
heavier or lighter case load would be far reaching for users of services as regards quality of care.
As regards adequacy of abortion care services, women in urban areas are better placed compared to
those in rural areas, fFable 3.5(a)). In general, ACFs in Pune district have to attend to
comparatively much lesser number of women than those in Ratnagiri district. In general, Pune
district exhibits a much better situation to that of Ratnagiri districts as regards abortion case load
per abortion care facility. (Table 3.5(b)). The trend does not necessarily continue across the tehsils
within the districts. For instance, Baramati, a comparatively more urbanised tehsil shows higher
case load than that of other comparatively less urbanised tehsils. However, in case of Ratnagiri
district, more urbanised tehsils (Ratnagiri and Chiplun) exhibit lower abortion case load compared
to less urbanised tehsils. If we assume that Baramati is a deviation, then this trend, in general is in
line with earlier trends and supports the overall hypothesis that better developed areas would be
better placed as regards adequacy ofabortion care services.
Chill
^Gpess to abortion care: Availability and approachability, affordability.
63
Table 3.5(a) Adequacy of abortion health care facilities
District
Pune
Ratnagiri
Tahsil
Baramati
Ambegaon
Junnar
Ratnagiri
Chiplun
Guhaghar
Khed
Mandangad
Rajapur
Abortion care
facilities
Urban
__ 24
___ 10
31
15
10
7
Rural
__ 14
14
9
_6
_5
5_
2_
4
Female Population*
Female population of
reproductive age**
Number of women of
reproductive age per
abortion care facility
Urban
21367
Urban
11260
Urban
469
Rural
10164
27577
19103
5590
3
5050
* Source:
129036
94068
141958
104626
112547
70264
92703
38289
95568
5356
Rural
60001
43741
66011
14533
10067
2945
2661
48651
52334
32672
43107
17804
44439
Rural
4285
3124
172
7334
968
8108
10466
6534
21553
4451
1007
420
887
■ cXSSSSSX4!.'A&■“:Village
‘
SX' SS
"
P‘n
■A 4 B D““
VlUv 4 t™
VIMe te
Pn„w
ss: ?lr1Sr“ara‘h“is 52-7 “d *5
chin
Access to abortion care: Availability and approachability, affordability.
64
Table 3.5(b) Adequacy of abortion health care facilities
District
Tahsil
Pune
Baramati
Ambegaon
Junnar
Abortion
care
facilities
_______ 34
_______ 28
40
Estimated number
Number of
of induced
abortions per
abortions*
abortion care facility
____________ 2484 ________________73
____________ 1498 ________________54
2436
61
Ratnagiri
Ratnagiri
21
2017
Chiplun
15
1998
Guhaghar
5
979
Khed
9
1461
Mandangad
4
544
Rajapur
3
1442
*Formulac used are as follows:
1) Birth rate = ( No. of live births * 1000)/ Population
2)Estimated no of abortion = No of live births x 25/73
3) Adjusted estimated no. of abortions = Estimated no. of abortions x 39/birth rate
4) Induced abortions = Adjusted estimated no. of abortions * 3/5
96
133
194
162
136
480
2. APPROACHABILITY TO ABORTION CARE SERVICES
Approachability to ACFs is assessed by studying the pattern of their geographical spread;
availability and nature of approach roads to them; mode of transport facilities and time
taken to reach them. Approachability also implies certain direct and indirect costs that
women bear to approach the facilities. Survey data on 159 ACFs are used for the purpose.
Further insights are gained from the data drawn from the abortion seeking women from
the sub-sample of ACFs studied in-depth for in the qualitative phase of the present
research.
2.1 Spatial spread of abortion care facilities
The 159 ACFs identified in the survey are plotted on the map by marking the boundaries
of the villages and/or townships which situated these ACFs to understand the pattern of
spatial distribution and distance to abortion care facilities (Fig. 2) that women have to
travel to access abortion care.
The skewed distribution of ACFs observed in the earlier section is an adequate indication
of the possible uneven distribution of ACFs. In general, both the districts exhibit an
uneven distribution pattern of the ACFs. But Pune district seems to have a better spatial
spread compared to that prevails in Ratnagiri district. Within the districts, Junnar in Pune
district seems to have a better spread compared to Ambegaon and Baramati. In case of
Ratnagiri district, tehsils do not differ much as regards this. All of them are characterised
by sparse and uneven distribution of abortion care facilities. The difficult terrain in
Ratnagiri would further worsen the situation for women as regards approachability to
abortion care facility.
Ch HI
Access to abortion care: Availability, approachability and affordability.
65
Even in rural areas, the ACFs are found to be concentrated in the villages with more than
5000 population. For instance, Manchar in Ambegaon teshil of Pune district; Narayangaon
and Otur in Junnar tehsil of Pune district which are more densely populated villages
compared to others have more number of ACFs. These data suggest positive association
between development status of the region and better spread of the ACFs.
Public ACFs, when present, always co-existed with the private ACFs. This, generally
wou d lead to underutilisation of public ACFs as users perceive that private HCFs are
better compared to public HCFs. Our earlier study has shown that women prefer private
ACFs over the public. This is because they perceive that their abortion specific concerns
vis-a-vis quality of care are better served by the former ones. (Gupte, et.al., 1999).
2.2 Approach road, mode of transport and time taken
The sparse and uneven distribution of ACFs requires better availability of approach roads
and transport facilities for women to have access to these facilities. We, therefore
examined the extent to which these sparsely and unevenly distributed ACFs are
approachable in this sense. Availability of state transport facilities was considered as a
crude indicator of connectivity of villages to outside world. This is because (a) it does not
tell us about their plying frequency, (b) it leaves out availability of other transport
facilities, and (c) absence of the state transport facilities does not necessarily and strictly
means non-availability of approach road.
As demonstrated earlier, the number of locations/villages/townships with ACFs situated
t erein are much less (Fig 2). The census data on availability of state transport facilities
show that a large number of villages are without such facilities. (Table 3 6(a)) As a result
it could be expected that women’s access to ACFs is obstructed. To one’s surprise the
average connectivity, at least in terms of availability of state transport facilities in Pune
district is poorer compared to Ratnagiri. There does not seem to be any plausible
explanation one can offer for this pattern. But, in both the districts more urbanised tehsils
exhibit much better connectivity compared to less urbanised ones. Poor connectivity
together with lesser number of locations with ACFs, such as, Junnar and Mandangad will
have compounding adverse impact on approachability to ACFs.
Ch III
Access to abortion care: Availability, approachability and affordability.
66
Table 3.6(a) Availability of transport facilities
District
Tahsil
Total number
of villages/
Townships with
a bus stop*
(connectedness)
105 (93.8)
72 (52.9)
35 (21.0)
212 (51.0)
198 (99,5)
161 (98.2)
53 (43.4)
192 (89,3)
17(15,6)
162 (74,3)
783 (76.2)
Number of
villages/
townships
with HCFs**
Number of
villages/
townships
with ACFs **
Baramati
112
26
Ambegaon
136
8
Junnar
167
12
Sub-total
415
46
Ratnagiri
Ratnagiri
199
10
Chiplun
164
7
Guhaghar
122
7
Khed
215
5
Mandangad
109
10
Rajapur
218
13
1027
Sub-total
52
* Census ** Our survey.
**Figures in parenthesis are percentages with the total number of villages/townships.
11 (9.8)
6 (4,4)
6 (3.6)
23 (5.5)
7 (3.5)
5(3.1)
3 (2.5)
3(1-4)
2(1.8)
1 (05)
21 (2.0)
Pune
Total
number of
villages/
townships *
Further, these aspects of approachability are also assessed with the help of the data on 39
women who sought abortion care services from a sub sample of 23 abortion care facilities
which were studied in-depth. The constraint of restricting analysis only to women
reaching ACFs is that those who do not use these services, perhaps for reasons of difficult
access, remain out of our purview.
Of the 40 women who sought abortion care at ACFs, 9 had to travel on unmetalled road,
25 on metalled road. In general, more women (8 of 28) in Ratnagiri travelled unmetalled
road compared to Pune (1 of 12). State transport facilities and private vehicles, such as,
rikshaws, two wheelers; jeeps were the various modes of transport used by women to
reach the abortion care facilities. In all, 18 women utilised public transport facilities, 14
used private transport such as, motorcycles, auto rickshaws or jeeps. Seven women
approached ACFs by walking generally ranging between 5 to 15 minutes, except one
woman walked for an hour to reach the ACF. One woman had use three modes of
transport to reach the ACF. Majority of women in Ratnagiri had used state transport
facilities whereas in case of Pune women used private transport facilities. Time taken to
reach abortion care facility ranged between five hours to a few minutes. On average
women took about 30 minutes to reach to ACFs. It differed across districts. In Pune
average time taken to reach ACFs was about 20 minutes whereas in Ratnagiri district it
was about 42 minutes. In case of Ratnagiri, the range of time taken to reach abortion care
facility is much larger compared to that in Pune. This could be attributed to the terrain
difference between the two districts. It is also likely that the ST buses ply less frequently
from interior villages to nodal points. The two districts are different on the three aspects
of approachability - type of road, mode of transport and time taken.
These data are not adequate enough, both size and methodology wise, to draw any
concrete inferences about association between approachability and women’s choice of a
particular ACF. However it gives glimpses of difficulties that women face on these
fronts.
Ch HI
Access to abortion care: Availability, approachability and affordability.
67
3. AfTordability/cost of abortion care services
It is examined with the help of costs incurred both on travel and for medical care by these
women. Indirect costs incurred by women could not be dealt with because it was the
facility based study. Information on cost of care was gathered from women themselves.
Women generally told us the costs incurred though a few did fumble.
3.1 Tavel cost
On average women incurred about Rs 64/- towards the travel to reach the facility. In
Ratnagiri it was Rs 72/- while in Pune it was Rs 55/-. Women, logically should be
incurring double of this towards the travel cost if one considers that about the same sum
would be spent on the way back home. Most of these women were accompanied by one
or more persons to ACFs. This travel cost includes the expenditure incurred for their
travel, too.
3.2 Medical care fees
Cost of abortion care in terms of medical expenses incurred is determined practically by
many factors regardless of whether they are rational determinant or not. These include,
length of gestation, type of procedure used, type of pre-diagnostics conducted, drugs used
and prescribed during and after the procedure, stay at the ACFs, its nature and its quality
and qualification of service providers. Lack of any regulatory mechanisms in place allows
these factors to be indiscriminate determinants of cost of abortion care.
We found a wide variation in the medical care cost of abortion that women told us. We
found it difficult to get the break up of the cost over different heads and thus hampered
any systematic analysis. However, we could observe some salient features.
In private ACFs, on average Rs 927/- were charged towards the medical procedure,
diagnostics used (such as, sonography, blood tests, urine pregnancy test, VDRL) and
drugs. Consistency in abortion fees was absent. However, the stay or in-admission and
sonography played a decisive role in hiking the abortion fees. But, abortion as an ‘office
procedure’ not requiring in-admission did not necessarily mean less fees to women. There
were trends indicating that qualification of the abortion service provider determines fees if
a particular abortion care situation is controlled for other variables such as ‘type of
procedure used’, ‘length of gestation’, ‘diagnostics conducted’ and ‘in-admission’.
Some of the examples of determining the fees indiscrimanately are presented below.
A woman who required a blood transfusion was charged Rs 1,000/- for a bottle.
An EP Forte injection to induce menstruation was chargedfor Rs 60/Sonography to confirm pregnancy costs women between Rs 175/- 350/-. The woman who
was charged Rs 350/- for sonography was in her second trimester.
Ch III
Access to abortion care: Availability, approachability and affordability.
68
In the public ACFs, women though did not have to pay fees for the procedure, they had
to spent on drugs.
This analytical description of medical cost of abortion care confirms that it is beyond
women’s control like in any other health care utilisation situation. The fees charged were
indiscriminate and average fee was exorbitantly high.
The total direct cost inclusive of both travel and medical care totals up close to monthly
minimum wages of India. The average per capita income for India is Rs 45/-. This shows
that for an average earning woman, it is almost either impossible to seek institutional
abortion care or if in case she does so, it would not be without getting indebted.
Against this backdrop, it needs to be noted that women’s abortion care needs are different
than their other illnesses including reproductive ones. Unaffordable cost of care may
prohibit women from seeking them. And unattended health care needs of women in
general would have adverse implications for her health. However, abortion care needs in
most of the situations can’t remain unattended. Unaffordable cost of abortion care simply
means forcing women to face unsafe abortion leading to increased burden of mortality and
morbidity. The ‘essential’ nature of abortion care would have multiplying adverse impact
on her health. This is because women at a given point of time, are likely to render priority
to abortion care needs ignoring their other health care needs, if any. The prohibitive cost
of abortion care in such situation makes them to face ill consequences of unsafe abortion
and ill health resulting from leaving other health care needs unattended. This contextual
analysis adequately suggests that prohibitive cost of abortion care would have far
reaching and multiplying ill effects for women "s health.
3.4 SUMMARY & CONCLUSIONS
By and large, the problems as regards access that plague general health care services,
stands true with abortion care facilities, too but in much more accentuated manner. They
translate for the latter causing problems of much severity because of the specific socio
cultural context of abortion.
Availability of abortion care services
•
In general, there is a wide scope for expansion of abortion care services both in
public and private health care service sectors as only about less than a quarter and less
than one third of respective sectors are engaged in abortion care service provision.
•
The scenario at the micro level compared to the national or the state level is
comparatively better as regards share of the health care services in abortion care
service provision indicating skewed contribution pattern.
•
The skewed distribution of the available ACFs in favour of urban areas leaves a large
number of rural population to be served by a much smaller proportion of the rural
based ACFs. This would have implications for quality of abortion care that rural
women may receive.
Ch HI
Access to abortion care: Availability, approachability and affordability.
69
•
A meagre proportion of the public ACFs in the total abortion care service provision
implies that women have to seek abortion care services at private ACFs at cost
forgoing their right to free abortion care at public ACFs.
•
This further implies that women with no or poor purchasing power would be
forced to trade of quality of care either by choosing inferior institution based
abortion care or non-institutional unsafe abortion providers.
•
Existence of a large number of non-registered abortion care facilities of the magnitude
of 5 NR-ACFs for every ACF in the private sector, insinuates that women are
exposed to illegal abortion care service provision which may also be unsafe.
•
Further, it also demonstrates poor implementation of the MTP legislation and
non-compliance on part of the heads of these institutions.
Except a meagre number, the majority of the rural based private ACFs are non
registered.
•
•
Urban areas are better placed as regards
i
' adequacy of“ ACFs
— meaning lesser case
load. This suggests better chances of receiving quality abortioni care services
compared to rural areas.
•
In general, development status of regions would exhibit positive correlation with
various aspects of ‘availability’ of abortion care services. There were some
exceptions to this, such as, extremely low compliance with legislative measures in the
developed district.
Consequently, the same is true with urban status of the region.
•
Approachability to abortion care services
•
•
In general, the smaller share of HCFs in abortion care service provision observed in
the study area consequently lead to their sparse and uneven spread.
There prevails positive association between the development status of the region and
better spread of ACFs conforming with the trends observed in case of other aspects of
access to abortion care services.
Affordability /cost of abortion care.
•
•
•
•
Women incur considerable cost towards travel to reach ACFs amounting to about 6.5
per cent of the total direct cost of abortion care.
Average medical care fees of abortion care were prohibitively high. They were wide
ranging indicating unregulated charges at private ACFs.
The prohibitive cost of abortion care may force women to approach unsafe abortion
care services, which would have far reaching ramifications for her health.
From women’s perspective, their own abortion care needs have the status of
essential’ and are of prime ‘priority’. If abortion care services are available mostly at
unaffordable cost, it would have multiplying ill-effect for her health as she faces
consequences of unsafe abortion care as well as that arising of ignoring other health
care needs.
Ch III
Access to abortion care: Availability, approachability and affordability.
70
CHAPTER IV
PHYSICAL STANDARDS:
INFRASTRUCTURE, EQUIPMENT & INSTRUMENT;
AND DRUGS
1. Type of abortion care
2. Physical standards
2.1. Types of various spaces available at the HCFs
2.2. Physical condition of spaces
2.3. Essentials
2.4. Complementary
3. Assessment of minimum physical standards: A composite analysis
4. Summary and conclusions
The present chapter uses the data drawn from the quantitative survey of the 115
study units. It deals with data on physical standards as operationalised in the QAC
model. It carries analysis along the three basic analytical categories, urban/rural,
public/private; and registered/non-registered status of HCFs when required.
1. Type of abortion care (FT and/or ST) across characteristics of ACFs
All ACFs, except one, provided first trimester abortion care. (Table 4.1). Of the total 115
ACFs, 70 ( 60.9%) provided abortion care up to 20 weeks. About one fifth (20.9%) of
the ACFs were engaged in providing abortion care even beyond 20 weeks, which,
according to the MTP Act is not permitted. They prevailed in both, urban and rural areas.
The public ACFs as well as private registered ACFs were no exception to this.
Table 4.1 Type of abortion care by characteristics of ACFs
Length of gestation*
Characteristics
ofHCF
Urban
Rural
All trimester
(FT,ST &TT)
Up to 20
weeks
(ST)
Upto 12
weeks
(FT)
71
43
46
24
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
13
11
Others**
2
2
71
Public________
Private_______
_____ Registered
Non-registered
_____ Total
161
8
2
23
15
75
114
47
70
6
16
24
1
_3
4
N=115
*The categories are not mutually exclusive.
** Others constitutes institutions providing abortion care (a) only between 13-20 weeks, (b) up to 12
weeks and beyond 20 weeks (FT+TT but not ST))
2. PHYSICAL STANDARDS
2.1 Types of various spaces available at the ACFs
Not all institutions had enquiry counters and special rooms. (Table 4.2). A large number
of institutions (35.7%) were not well placed with regard to having separate spaces for
operation theatre and labour room, a requirement from the point of view of maintaining
the minimum hygienic and sterile conditions at operation theatre. (Table 4.3).
The data show that urban/rural, public/private and registered/ non-registered status of
ACFs has association with availability of separate spaces for OT and LR. (Table 4.2). A
larger proportion of the urban ACFs and the majority (77.5%) are with separate OT and
LR compared to rural based ones. A substantial number (22.7%) of rural based ACFs are
without OT. The majority of the public ACFs are with separate spaces for OT and LR.
The majority of the private registered ACFs had separate OT and LR. Only about half of
the private non-registered ACFs were characterised of separate spaces for OT and LR. A
very clear trend shows across the size (in terms of number of beds) of the ACFs. Smaller
the ACFs, less likely they are to have separate OT and LR.
In substantial number of ACFs the same space was sharedfor labour room and operation
theatre. This should be the cause of concern as it means that the users, especially of
surgical care including abortion care service are subjected to less than sterile conditions
and would be more likely to suffer post operative morbidity post operatively.
Table 4.2 Types of spaces available at ACFs
Type of spaces
Number & % of ACFs with such
spaces
64 (55,7)
113(98,3)
111(96,5)
53 (46,1)
111 (96,5)
114(99,1)
Enquiry counter
_________________
Waiting room__________
Wards*
Special rooms_____________
Consulting room___________________
Labour room(LR) and/or Operation theatre (OT) **
N=115
*Partitioned and/or open space has not been counted as wards. However, it was difficult to distinguish
between shared rooms (more than two beds) and/or general rooms and wards. Thus, all these three
categories were considered as wards.
** LR and OT were found to be the same at certain institutions. Refer Table 4.6(a)
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
72
Table 4.3 Separate spaces for operation theatre and labour room by characteristics
of ACFs
Characteristics of
the ACFs
Urban
Rural
Public_______
Separate spaces for operation theatre and labour room
Separate
Same
Only LR
None
Total
OT&LR
OT&LR
55 (77.5)
14(19.7.)
71 (100.0)
1 (1-4)
1 (1-4)
19(43,2)
15(34.1)
10 (22,7)
44 (100.0)
1 (6-3)
16 (100,0)
2 (8,7)
26 (34,2)
10(13,2)
1 (1-3)
23 (100.0)
76 (100,0)
29 (25.2)
11 (9.6)
1 (0.9)
115 (100.0)
14 (87,5)
1 (6-3)
______ Regtrd
Non-Regtrd
21 (91.3)
39(51,3)
Total
74 (43.2)
Private______
2.2 Physical condition of spaces
Waiting rooms (Table 4.4 (a)): At the majority of the ACFs, the waiting rooms were
found to be with adequate ventilation, sufficient light and were clean. Waiting rooms at
about 9.6 per cent ACFs were with seepage. Little more than half of the ACFs had no
drinking water facilities at waiting rooms. Waiting room at about 37.4% of the ACFs
were overcrowded.
Consulting room (Table 4.4(a)): Even the consulting rooms were not free of various
inadequacies in terms of the above mentioned characteristics. About a quarter (23.5%) of
the institutions had their consulting rooms overcrowded, as was true with waiting rooms.
More than one client at a time inside the consulting caused this problem (37.5%) as per
our observation. The consulting rooms at about 42.6% of the ACFs lacked aural privacy
as the conversation between the service provider and the user was heard outside.
Table 4.4(a) Condition of waiting rooms, wards, special rooms and consulting room
Features
Ventilation (adequate)_________
Light (sufficient)_____________
Cleanliness (present)__________
Seepage (absent)_____________
Sink (present)________________
Water facility at the sink (present)
Drinking water (present)_______
Overcrowding (absent)_________
Bathrooms
Toilets
Waiting
Room
113 (98,3)
112(97,4)
112(97.4)
104 (90,4)
NA
NA
56 (48,7)
72 (62.6)
NA
NA
Number & % of ACFs
Wards
Special
rooms
99 (89.0)
52 (98.1)
104 (93.7)
53 (100,0)
91 (82,0)
52 (98,1)
86 (77.5)
45 (85,0)
NA
NA
NA
NA
87 (78,4)
41 (77.4)
90 (81.1)
48(41.7)
37(33.33)
35 (66.0)
(separate)
(attatched)
37(33.33)
35 (66.0)
(separate)
(attached)
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
Consulting
rooms
107 (93.0)
109 (94,8)
105 (91,3)
95 (82.6)
64 (55.7)
63 (54,80
29 (25.2)
88 (76,5)
NA
NA
73
Provides Privacy__________
Aural/audio (yes)__________
More than one client inside (not
found).__________________
Total
♦
NA
NA
66 (57,4)
72 (62.6)
115 (100.0) 111 (100.0)*_________
53 (100.0)*
Only those institutions having these spaces are considered while calculating the percentages.
115 (100.0)
NA
NA
NA
NA
Special rooms and wards (Table 4.4 (a) & 4.4 (b)): The so called special rooms at all
institutions were not necessarily with attached bathrooms and toilets, perhaps a major
deviation from the concept of ‘special room’ itself Besides, special rooms being
overcrowded also suggests that the concept is conceived differently than that in the cities
and comparatively developed areas. Not all spaces were free of seepage etc., for instance
like waiting rooms. Analysis across the characteristics of the ACFs (Table 4.4(b)) indicates
that at majority of the ACFs, there were no separate sanitary blocks for the wards.
Majority of the rural based ACFs were without special rooms. Except one, no public
ACFs had special rooms. About half of the private ACFs had special rooms.
Table 4.4 (b): Special rooms by Characteristics of the ACFs
Characteristics of the ACFs
Whether special rooms exist
No
~
27 (38,0) T~
35 (79.5)
Total______
71 (100.0)
44 (100,0)
Urban
Rural
Yes
44 (62,0)
9 (20,5)
Public
1 (6.3) |
15 (93,8)
16 (100.0)
19 (82,6)
33 (43.4)
S3 (46.1)
4 (17,4)
43 (56,6)
62 (53.9)
23 (100.0)
76 (100.0)
115 (100.0)
Private
Regtrd
Non-Regtrd
Total
Operation theatre and Labour room (Table 4.5): OTs at a substantial number of
institutions (17.5%) were with seepage, affecting very obviously the necessary hygienic
conditions at the operation theatre. The basic facilities, such as sink (regardless of what
form they are) and water at sink were lacking at operation theatre at more than half of the
institutions with OTs. Only about less than 40 per cent of the institutions having LRs
were with attached toilets and bathrooms.
Ch IV
Physical standards: Infrastrucuire; equipment & instrument; and drugs
74
Table 4.5 Condition of Operation theatre and Labour room
Features
Number & percentages of Institutions
Exhaust fan ZAC (present)
Light (sufficient)_______
Cleanliness (present)
Seepage (no)_________
Sink (present)_________
Water facility (running)
Drinking water (present)
Bathrooms (available)
OT
(N= 103)______
87 (84,5)
______ 99 (96,1)
93 (90,3)
85 (82,5)
60 (58,3)
55 (53.3)
__________ NA
NA
Toilets (available)
NA
LR
(N=85)______
________15 (17,7)
_______ 82 (96.5)
_______ 72 (84,7)
_______ 72 (84,7)
_______ 69 (81.2)
_______ 61 (71,8)
_______ 33 (38,8)
32 (37.6)
_______ (attached)
35 (41.2) (attached)
Toilets and bathrooms at the institutions (Table 4.6(a) & 4.6(b)): Of 115 institutions,
3 did not have toilets and one was under construction. All three were private ACFs; 1
was urban based; all three were non-registered. Substantial number of institutions lacked
the basic hygienic conditions at the sanitary block. In that, lack of cleanliness at sanitary
block at as large as about 43.5 per cent of the institutions is certainly a cause of concern.
However, comparatively a large number (94 of 111 with toilets) of institutions with
running water at sanitary block/s, was consoling, especially against the fact that 38.23 per
cent of the institutions in the sample are rural based. At some ACFs, we were told that the
entire set up did not have running water but the toilets and bathrooms were provided with
running water. Of the 17 which did not have running water, were mostly from rural areas
and were private ACFs.
Toilet facilities at ACFs in general and at those which are engaged in women specific
health care services assume significance for obvious reasons. Lack of clean toilet facilities
with ample water for use certainly exposes women to infections who often are required to
use them, especially when required to undergo PV examination. We observed that even at
the large private health care facilities and the public health care facilities, these facilities
were either absent or when present were extremely unclean, almost in non-usable
condition. Women had no choice but to use them.
Lack of basic hygienic condition at sanitary blocks at about 43.5 per cent ACFs was quite
puzzling. This is because substantial number of ACFs (94 of 111 ACFs) had running
water in the sanitory blocks. The answer perhaps could be found in the fact that in general
our health care facilities are characterised by lack of maintenance. Inadequate staff should
cause such ill-maintained situation. Heads of the institutions and other concerned
authorities often tend to attribute this to their inability to support such staff for lack of
finances. And above all there prevails a tendency to blame and hold responsible the
“uneducated and in-hygienic” lot of clients to cause such a situation. By many, any extra
effort to maintain hygienic condition is excused by the institutions as they hold a view that
‘they do not deserve any better services’. However, more than anything else it certainly is
a result of low priority of owners of the health care facilities for clients ’ right to clean
and hygienic health care services.
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
75
Table 4.6(a) Conditions of toilets and bathrooms at the ACFs
_____________Characteristics
Cleanliness (yes)___________
Airy (yes)_________________
Light (adequate)____________
Running water (present)
N=115
Number & percentage of the ACFs_____
__________________________ 65 (56,5)
__________________________ 74 (64.3)
__________________________ 87 (75,7)
94 (81.7)
Table 4.6(b) Toilets and/or bathrooms without running water by characteristics of ACFs
Characteristics of the ACFs
Number and %
Urban
Rural
5 (29.4)
12 (70,6)
Public
Private
7 (43.8)
10(10.1)
Rcgtrd
8(47.1)
9 (52,9)
17 (100.0)
Non-Regtrd
Total
3. Essentials: equipment, instruments, drugs and facilities
3.1.a Essential equipment (Table 4.7(a)): A substantial number of institutes engaged in
abortion care were not equipped with the essential equipment as stated in the MTP Act.
Oxygen cylinders and Boyles’ apparatus were available in-house, when they were. In case
of other equipment, anaesthetist/s supported the ACFs with their own set of equipment.
Percentage of such ACFs varied from about 6.9 to 10.4. Percentage of ACFs having these
equipment in-house varied from about 60.9 to 68.7. Boyle’s apparatus was available only
at about 29.6 per cent of the institutions. The majority of the institutions were equipped
with oxygen cylinders. There was no operation table at 7 ACFs.
Table 4.7(a) Essential equipment/instrument required either for anaesthesia and/or
resuscitation; sterilisation and availability operation table
Sr No
Description of the equipment
Number & % of the ACFs
In-house
2
3_
£
5_
6
Equipment required for
anaesthesia and/or resuscitation
Oxygen cylinder ____________
Breathing hoses______________
Self inflating bags____________
Airways____________________
Endotracheal tubes___________
Boyle’s apparatus*
Brought by
Not
service
available
providers
96 (83.5)
76 (66.1)
70 (60.9)
74 (64.4)
79 (68.7)
34 (29,6)
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
11 (09.6)
12 (10.4)
10 (08.6)
8 (06,9)
16(13.9)
25 (21,7)
30 (26.1)
28(24.3)
25(21,7)
78 (67.8)
No
Data
3 (2,6)
3 (2.6)
3 (2.6)
3 (2.6)
3 (2.6)
3 (2.6)
76
2
2
___ 1
Sterilisation Equipment
Autoclave____________
Pressure cooker_______
Furniture____________
Operation table
104 (9Q.4)
8 (07.0)
10 (08,7)
106 (92.2)
1 (0.9)
1(0.9)
105 (91.3)
7(06.1)
3 (2.6)
N=115
* This is exclusively required for administering anaesthesia. The rest are essential for both anaesthesia
and resuscitation.
S.l.b Essential equipment for anaesthesia and resuscitation: A composite analysis
(Table 4.7(b)): A composite analysis was done to understand whether a particular ACF
was equipped with all the essential equipment required for administering anaesthesia
and/or resuscitation when needed,1.
Analysis of this composite variable/index across characteristics of the ACFs indicates that
only little more than quarter (27 %) of the ACFs are equipped fully and completely with
essential anaesthetic and resuscitation equipment. Of all a majority (about 60 %) was only
partially equipped. This pattern persisted within all the categories, such as urban, rural and
public and private NR-ACFs. For instance, a majority of the urban based ACFs and little
more than half of the rural based are only partially equipped. And about more than a
quarter of the rural based were not at all equipped. Only about one fourth of the public
ACFs are fully and completely equipped and a majority was only partially equipped. The
private registered ACFs exhibit a better pattern compared to the other categories as about
more than half of them were fully equipped leaving about little less than half being partially
equipped. Of the total private NR-ACFs, only about one fifth were fully equipped. A
substantial number of them was not equipped at all.
It is to be noted that, public ACFs are no exceptions to ‘not being equipped’ with as
essential equipment as anaesthetic and resuscitation. And the registered status of ACFs
does not ensure being fully equipped. At the same non-registered status does not
necessarily mean being ill-equipped.
1 HCFs if had all the essential equipment for anaesthesia and resuscitation were considered as HCFs with
‘all equipment available’; if had even one of them less, were treated as ‘partially equipped’; and those with
none of the equipment were considered as ‘none’ in the composite analysis.
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
77
Table 4.7(b) Availability of essential equipment (anaesthesia & resuscitation) by
characteristics of ACFs
Characteristics
of the ACF
Urban
Rural
Availability of essential equipment (anaesthesia & resuscitation)*
Completely **
Equipped
24 (33,8)
7(15,9)
Partially
equipped
45 (63,4)
23 (52.3)
None at all
No infn
1 (1.4)
12 (27.3)
1 (1.4)
2 (4.5)
Total
71 (100.0)
44 (100.0)
Public________
1 (6.3) |
4 (25.0)
10 (62,5)
16 (100,0)
1 (6.3)
Private______
______ Regtrd
12 (52.2)
11 (47,8)
23 (100.0)
Non-Regtrd
15 (19,7)
47 (61,8)
12(15.8)
2(2.6)
76 (100.0)
Total________
31 (27.0)
68 (59.1)
13 (11.3)
3 (2.6)
115(100.0)
*Six instruments/equipment were listed as minimum physical standards requirement for administering
anaesthesia and/or to meet resuscitation needs.
* Completely equipped: ACFs with all six instruments/equipment
Partially equipped : ACFs with less than six instruments/equipment
Lack of equipment : ACFs with none of the six instruments/equipment
3.3.a Essential instruments for MTP procedure (Table 4.8(a)): The majority of the
institutions seem to be meeting the needs of the instruments and/or equipment required for
the first trimester MTPs. A large number of institutions (45.2%) are not equipped with
laparotomy equipment and the majority (74.8%) lack laparoscope. These institutions
therefore are short of meeting the requirements for conducting second trimester MTP
procedures. A small percentage of institutions are supported by the service providers with
regard to these equipment by bringing their own sets of the material. It is to be noted that
114 of the 115 institutions provide first trimester abortion care and 70 institutions provide
second trimester abortion.
Table 4.8(a) Essential equipment/instruments for MTP procedure
Sr No
Description of abortion specific
instrument and equipment
Number & percentage of the institutions
In-house
_2
2
4
2
6
7
8
Required for both first and second
trimester abortion care____________
Set of dilators (different sizes)
Vulsellum forceps
Ovum forceps
Long ovum forceps (with narrow top end,
transverse serrations and a racket in the
handle for locking)__________________
Curette
Suction machine (electric/hand/foot
pump)*
________________________
Sim’s speculum
Suction cannula
Brought by
service
providers
Not
available
Data
No
92 (80.0)
93 (80,9)
5(4.3)
5(4.3)
9 (7.8)
15 (13.0)
9 (7,8)
2(1.7)
94 (81.7)
5 (4.3)
14(12.2)
2(1.7)
94 (81.7)
98 (85.2)*
5 (4.3)
3 (2.6)
14 (12,2)
13(11.3)
2(1.7)
1 (0.9)
97 (84,3)
84 (73,0)
5 (4.3)
5 (4.3)
11(9,6)
24 (20,9)
2(1-7)
2(1.7)
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
78
Required for second trimester, in
addition to the above ones
Catheter (Folly's / Simple rubber)
Laparotomy equipment_______
Laparoscope
___ 1
88 (76,5)**
5 (4.3) 17 (14,8)
5 (4,3)
2 •
56 (48,7)
3(2.6) 52 (45,2)
4 (3,5)
__ 3
22(19,1)
4 (3.5) 86 (74,8)
3 (2,6)
N=115
* This includes three types of suction machines - electric, hand operated and foot operated. 82 institutions
have electric suction machines, either by itself or in combination with hand or foot operated.
** Of these, at 5 institution, it is prescribed and at other two, it is not used for MTP procedure.
3.3.b Essential instruments for MTP procedure: A composite analysis(Table 4.8(b))
A similar type of composite variable as was done for anaesthetic and resuscitation
equipment was constructed to get a comprehensive idea about the proportion of fully
equipped ACFs as regards MTP procedures. This shows that about 62.6 per cent of the
ACFs are fully equipped.
Proportion of fully equipped urban ACFs is better than that of proportion rural ACFs; and
of the private registered ACFs is better than that of private NR-ACFs. The proportion of
‘partially equipped’ was substantial across all the three characteristics of the institution. As
large as 43.8 per cent of the public ACFs are equipped only partially. And a little more
than a quarter of the private registered ACFs were only partially equipped.
Table 4.8(b) Availability of essential equipment for FT by characteristics of ACFs
Characteristics
of the HCF
Urban
Rural
Availability of essential equipment for FT*
Fully
equipped
48 (67,6)
24 (54,5)
Partially
eqipped
21 (29,6)
16 (36,4)
Lack of
equippment
________ 2 (2,8)
________ 4(9.1)
Total
71 (100,0)
44 (100,0)
Public_______
9 (56,3)
7 (43.8) I
16 (100,0)
Private______
_______ Regtrd
17(73.9)
6(26,1)
23 (100,0)
Non-Regtrd
46 (60.5)
24 (31,6)
6 (7,9)
76 (100.0)
Total
72 (62.6)_______________________________________
37 (32.2)
6 (5.2)
115(100.0)
* Fully equipped. ACFs with all the 7 equippment/instruments required for abortion procedure,
Partially equipped: ACFs with less than 7 instruments required for abortion procedure,
Lack of equippment; ACFs with none of these instruments
3.4.a Life saving/emergency drugs (Table 4.9(a)): Data show that even the ‘emergency
drugs’ are not stocked by all the institutions
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
79
Table 4.9(a) Availability of life saving/emergency drugs
Sr
No
1,
2,
3,
4,
5,
6,
7,
8,
9,
N=115
Life saving/emergency drugs
Adrenaline__________________
Glucose I.V._________________
Ringer lactate________________
Hydrocortisone inj. (Efeorline) /
Dexamethasone______________
Mephensine inj.______________
Avil inj,_______________ _____
Dopamine___________________
Soda bicarb._________________
Frusemide
Number & percentage of the institutions
_____ where drugs are available______
________________________107 (93,0)
________________________111 (96.5)
________________________110(95.7)
103 (89.6)
99 (86,1)
110(95,7)
81 (70,4)
107 (93,0)
100 (87.0)
3.4.b Life saving/emergency drugs: A composite analysis (Table 4.9(b)
A similar type of composite variable as was done for anaesthetic and resuscitation
equipment was constructed to get a comprehensive idea about the proportion of fully
equipped ACFs as regards life saving drugs. This shows that only about 60 per cent of the
ACFs seem to stock all the life saving drugs.
Proportion of urban ACFs with all the life saving/emergency drugs is much better than
proportion rural ACFs. Proportion of private ACFs with all the life saving/emergency
drugs is more than double the proportion public ACFs. Poor drug supply to PHCs has
been documented by an earlier study. (Phadke, A., 1998). The majority (60% or more) of
the private ACFs, both registered and non-registered were found to have stocked all
essential drugs though the R-ACF were further better placed. However, neither the urban
based, or public or R-ACFs were exception to being ‘not fully equipped ACFs’ as regards
life saving/emergency drugs. And such proportion was substantial across all these three
characteristics of the institution.
Table 4.9(b) Availability of life saving/emergency drugs by characteristics of ACFs
Characteristics
of the HCF
Urban
Rural
Availability of life saving/emergency drugs*
Completely**
stocked_____
51 (71.8)
18 (40.9)
Partially
stocked
20 (28,2)
23 (52.3)
None
3 (6.8)
Total
71 (100,0)
44 (100.0)
Public________
10 (62.5) |
5(31.3)
1 (6.3) |
16 (100.0)
Private______
______ Regtrd
19 (82,6)
4 (17.4)
23 (100,0)
Non-Regtrd
45 (59,2)
29 (38.2)
2 (2,6)
76 (100,0)
Total________
69 (60.0)
43 (37.4)
3 (2.6)
115(100.0)
* Nine drugs were listed as life saving/emergency drugs.
** ACFs with all 9 of them are coded as ‘Completely stocked’; with less than 9 of them are coded as ‘partially
stocked’ & with no drugs are coded as ‘lack of life saving drugs’.
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
80
3.5 Essential facilities (Table 4.10) : About 27 per cent (31 of 115) institutions did not
have any back up in terms of generator set in case of failure of electricity supply, not even
for operation theatre. Ambulance and fire fighting arrangements seemed a low priority for
most of the institutions
Table 4.10 Essential facilities
Sr
No
1
l.a
l.b
l.c
l.d
Generator set for :_____________
Operation theatre alone__________
OT & Emergency wards/rooms only
OT and LR only________________
Entire setup
22(19,1)
7(6.1)
2(1.7)
53 (46.1)
2
Ambulance
30(26,1)
3
3,a
3.b
Fire fighting arrangements available:
Fire extinguisher_________________
Easily accessible water supply_______
Fire extinguisher and easily accessible
water
9 (7,8)
27 (23.5)
4(3.5)
3.c‘
Item
Number & percentage of the ACFs where
they are available
N=115
2.4 Complementary services and facilities
4.1.a Complementary services (Table 4.11): Only about one third of the ACFs had in
house pathology laboratories. The various tests that are listed above, ideally speaking, are
expected to be conducted. However, m case the providers at these institutions prescribe
these tests for their abortion clients, women had to get these tests done from outside the
HCF.
Table 4.11 Complementary services
Sr
No
1
l.a
l.b
l.c
l.d
2
2.a
2.b
2,c
N=115
Type of services
In-house Pathology laboratory (yes)
Urine tests conducted____________
Urine sugar_____________________
Albumin_______________________
Urine microscope________________
Pregnancy
Number & percentage of the institutions
______ where they are available________
38 (33.0)
Blood tests____________
Blood group (including Rh)
Hb percentage (Hb)______
Blood sugar
Ch IV
Physical standards: Infrastructure; equipment & instrument; and drugs
38 (33.0)
37 (32,2)
33 (28.7)
33 (28.7)
34 (29,60
37 (32.2)
32 (27.8)
81
4.1.b Access to Blood bank: We have earlier seen in chapter III that 114 of the 115 of
our sample ACFs were engaged in providing abortion care up to 12 weeks of gestation,
and only 70 of 115 were providing abortion care up to 20 weeks.
As anticipated, none of the rural based ACF providing abortion care up to 20 weeks had
access to blood bank. (Table 4.12). Even in case of urban institutions only a little more
than half (56.5%) met the legal requirement of access to blood bank.
Surprisingly, even the public ACFs were found to be violating the law as regards access to
blood bank. Of the 8 public institutions providing abortion care up to 20 weeks of
gestation, only 2 had access to blood bank as stipulated in the MTP Act.
Only about 9 (39.1%) of 23 registered MTP centres providing abortion care up to 20
weeks of gestation had blood bank within 5 km.
We conclude that urban institutions stand a better chance of access to blood bank at a
distance of 5 km or less. Either ‘registered’ or ‘public’ status of the abortion care centre
did not ensure compliance with legal specification regarding access to blood bank.
Table 4.12: ACFs engaged in abortion care up to 20 weeks and their access to blood
banks
Characteristic
s of ACFs
Urban________
Rural_________
Public________
Private_______
Registered
Non-registered
Total
Distance at which blood bank was situated
5 km or less
26 (56.5)
2 (25,0)
7 (46,6)
17(35,0)
26 (36.6)
More than 5 km
10(21.7) '
19(76,0) ~
4 (50,0) '
Total
No access at all
10(21.7)
6 (24,0)
2 (25.0)
46(100,0)
25 (100.0)
8(100,0)
3 (20,0)
11 (22.9)
16 (22.5)
15 (100.0)
48 (100,0)
71 (100.0)
5 (33.3)
20 (41.7)
29 (40.8)
2.4.2 Complementary facilities (Table 4.13): The majority of the ACFs had telephone
facility, though not all. Proportion urban (69.0) was slightly higher than proportion rural
(65.9) with telephone facility. Proportion private (72.7%) was much higher compared to
proportion public (37.5) ACFs equipped with telephone facility. Food facility at the
institutions even for clients seemed a rare facility.
Sr
No
1
__ 2
2.a
2.b
2.c
N=115
______ Table 4.13 Complementary facilities
Type of facilities
Number & percentage of the ACFs where
_________ they are available______
Telephone facility (available)
78 (67,8)
Food facility available for :
Users of health care (clients)
Users and relatives_______
Room/gas for cooking
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
4 (03,5)
1 (00.9)
9 (07.8)
82
3. ASSESSMENT OF MINIMUM PHYSICAL STANDARDS: A COMPOSITE
ANALYSIS
Complete set of equipment/instrument for conducting abortion procedure;
for
administering anaesthesia and/or to meet resuscitation needs; complete set of life saving
/emergency drugs and an operation table are considered to constitute the minimum physical
standards for providing abortion services at a particular HCF. Health care institutions,
therefore, were assessed to examine the extent to which they were equipped with these
minimum physical standards.
Composite analysis (Table 4.14) brings down the number of ACFs which meet the
minimum physical standards requirements in totality to as low as 18, constituting a mere
15.7 per cent of the total 115 ACFs studied. Majority of the ACFs are equipped with either
three or two of the four sets of physical standards requirement. Proportion of the
completely equipped ACFs as regards minimum physical standards is better in case of the
urban based compared to rural based, in private ACFs compared to public, and in
registered ACFs compared to non-registered ones.
Table 4.14 Availability of minimum physical standards for abortion care by
characteristics of ACFs
Characteristics
of the
institutions
Urban
Rural
Availability of essential equipment and life saving drugs*
All**
essentials
14 (19,7)
4(9.1)
Three
essential
32 (45,1)
9 (20,5)
Two
One
None
16 (22,5)
17 (38,6)
7 (9,9)
9 (20,5)
2 (2,8)
5(11.4)
Total
71 (100)
44 (100)
Public________
4 (25.0) |
2 (12,5)
3(18,8) I 6 (37,5)
16 (100)
1 (6.3)
Private_______
8 (34,8)
____ Registered
10 (43,5)
4 (17.4)
23 (100)
1 (4.3)
Non-registered
8 (10,5)
28 (36,8)
23 (30,3)
11 (14,5)
6(7.9)
76 (100)
Total________
18 (15.7)
41 (35.7)
33 (28.7)
16 (13.9)
115 (100)
7 (6.1)
* These include (1) complete set of equipment/instrument for conducting abortion procedure; (2) complete
set of instruments and equipment for administering anaesthesia and/or to meet resuscitation needs; (3)
complete set of life saving /emergency drugs and (4) an operation table.
**A11 essential: ACFs with all tlie above mentioned sets
Three essentials: ACFs with three of the four essentials instruments/equipment and drugs
Two essentials: ACFs with any two of the four essential instruments/equipment and drugs
One essential: ACFs with any one of the four essentials instruments/equipment and drugs
None
: ACFs with none of the four essentials instruments/equipment and drugs
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
83
4. SUMMARY & CONCLUSIONS
Availability of spaces and their physical condition
■
By and large the spaces or zones, such as, waiting rooms, wards, consulting rooms
were available at almost all health care facilities.
■
At substantial number of ACFs the same space was shared for labour room and
operation theatre. This consequently would subject the users of health care services,
especially of surgical care including abortion care, to less than sterile conditions. Users
as a result, would be more likely to suffer morbidity post operatively.
■
There was lack of basic hygienic condition at sanitary blocks at about 43.5 per
cent ACFs despite availability of running water. These are potential situations to
cause infections to the users. It also suggests a low priority of owners of the health
care facilities for clients’ right to clean and hygienic health care services.
Availability of essential equipment, instruments and drugs
■
Only little more than a quarter (27 %) of the ACFs was equipped fully and
completely with essential anaesthetic and resuscitation equipment. Only a quarter
of the public ACFs were completely equipped . Only about half of the private R-ACFs
were completely equipped with these essentials.
■
About 62.6 per cent of the ACFs were fully equipped as regards the surgical
instruments requiredfor MTP procedures. Only a little more than a half of the public
ACFs was equipped fully. About little less than three quarters of the private R-ACFs
were fully equipped.
■
About 60 per cent of the ACFs stocked all the life saving drugs. Only about a
little less than one third of the public ACFs were completely stocked with essential
drugs. A large majority of the magnitude of a little more than four fifths of the private
R-ACFs was completely stocked with essential drugs.
■
About 73 per cent ACFs were equipped with generator sets at OTs to manage the
situations of failure of electricity supply. This as a consequence leaves a substantial
number of users at risk who avail services from the rest of the facilities.
■
Composite analysis of essentials (equipment, instruments and drugs) has
brought down the number of fully equipped ACFs for safe abortion care services
to as meagre as 18 ACFs of 115. Of these, 2 were public and 8 each were private RACFs and NR-ACFs.
■
This clearly indicates that women have weak chances of receiving abortion care in
an infrastructurally sound and equipped set up. This, as a consequence, exposes
women to fatal risks.
■
It once again proves that neither the public ACFs nor the private registered ACFs
comply with the MTP Act as regards stipulated minimum physical standards.
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
84
■
At the same, it again proves that not all non-registered ACFs are unsafe as regards
abortion service provision.
■
It also reflects on the fact that the MTP Act is being poorly implemented.
Availability of complementary services and facilities
■
Only about one third or less ACFs had in-house facilities to provide services,
such as, pathological diagnostics. Lack of these complementary services in-house
causes not only physical inconvenience in terms of time, energy and money but women
also have to desist their concerns and priority for ‘confidentiality’.
■
There were no complementary facilities, such as, boarding arrangements,
telephone facilities at about 93 to 97 per cent of the ACFs. Absence of these
would cause inconvenience, for obvious reasons, to women seeking abortion care
and to those who accompany her.
■
Thus, the majority of the ACFs are neither sound in terms of medically prescribed minimum
physical standards nor do they meet women’s expectations of quality of care.
Ch IV
Physical standards: Infrastrucutre; equipment & instrument; and drugs
85
Chapter V
HUMAN POWER: AVAILABILITY, STRENGTH &
PROFESSIONAL COMPETENCE
Heads of institutions
Abortion care service providers
Anaesthetists
Consultants
Laboratory Technicians
Nurses
Aayas and ward boys
Professionally competent service provider and essential services: a composite
analysis
9. Summary and conclusions
1.
2.
3.
4.
5.
6.
7.
8.
The chapter presents data on human power at sample 115 ACFs in the study area. As
explained in the quality of abortion care model, the heads of the institutions (HI) as
administrative heads, abortion care service providers (APs), anaesthetists (ANs),
laboratory technicians (LTs), nurses, aayas, ward boys and enquiry attendants constitute
human power at ACFs. Of these APs and ANs form essential service providers while
the rest form complementary ones.
An assessment of human power in made in terms of (1) availability of professionally
competent service providers and (2) their numerical strength1. Data obtained from
115 sampled ACFs on these aspects are used for the purpose. Differential across
urban/rural; public/private and registered/non-registered are examined. For each of the
service provider categories, the data are organised along the two aforesaid aspects.
We found, as often is the case in health care delivery system, that individuals played more
than one role vis-a-vis one particular ACF. For instance, an HI was also an AP for a
particular ACF and was the dominant trend that we observed in the study area. Besides, a
particular service provider from some of the above mentioned categories, rendered her/his
services to more than one ACF. As result, we observed that in a given restricted
geographical area, a group of service providers formed the network of service provision
by catering to more than one service delivery points. This was observed especially in case
of APs and ANs. This we treated as a service link/contract. Thus, an individual service
provider had more than one type of relationship with a particular ACF and one
particular ACF had multiple service providers. This has implications, either positive or
negative, to users of services depending upon the extent to which qualified professionals
are engaged in attending multiple service delivery points.
1 Staff strength in terms of adequacy vis-a-vis case/client load is a useful concept for assessment of quality
of care. However, we did not study it for lack of systematic data on client load.
Ch V
86
Human power: Availability, strength & professional competence
An individual institution remains the unit of analysis as was the case for data presented in
the earlier chapters. In addition, it was required to analyse services links established
through service provision by an individual to a one or more ACFs.
1. HEADS OF INSTITUTIONS (His)
Heads of the institutions are the administrative heads of the health care facilities. Though
they need not necessarily be medicos, in Indian context they often are. They, therefore,
are termed as owner-doctors. Regardless of their medical background, they certainly are
the decision-makers and managers of the set-up. The managerial decisions and policy visa-vis the set-up are decided by them. Quality of care that is available depends much upon
their decisions. As far as abortion care is concerned, they would also play an important
role in deciding as which women could avail of abortion care services.
1.1 Profile: Males though dominated (65.2%) the position of head of an institution,
substantial number (34.8%) of institutions were headed by females. All His were medicos.
About a little more than two fifths of the His were qualified for abortion service
provision as they were either gynaecologists- either post graduates or diploma holders or
were trained in conducting MTPs. Non-allopaths headed about a little less than one third
ofACFs.
1.2 Qualification of heads of institutions by characteristics of ACFs (Table 5.1)
Except about one fifth (21.1%), the rest of the urban based ACFs were headed by
allopaths. About half of the urban ACFs were headed by gynaecologists. The pattern was
almost exactly reverse in case of rural based ACFs. About 45 per cent of them was headed
by the non-allopaths. This also confirms the earlier researched trends as regards general
health care services that allopaths are less attracted to rural areas to establish their practice
leaving larger rural population at hands of non-allopaths who often engage themselves in
cross practice.
A much larger number of the private ACFs was headed by gynaecologists compared to the
public ACFs. Of the total ACFs headed by gynaecologists, except two, the rest all were
private ACFs. Two of the public ACFs were headed by non-allopaths. This suggests that
the public ACFs are mostly supported by non-specialisedpractioners. Lack of availability
of health care services of gynaecologists has been articulated even by rural women and
thus their choice for private practitioners, almost out of ‘no choice’ situations’.
Of the total private R-ACFs a large majority (87%) was headed either by gynaecolgists or
MTP trained allopaths. In case of the private NR-ACFs, such a proportion was only less
than one third. However, inferences about safety of abortion care services would not be
drawn based on this as ACFs are expected to acquire MTP registration against
qualification of AP/s and not of HI. At the same, given the low compliance with any of
the medical legislations on part of the medical fraternity in general, it would not be
surprising to find if unqualified His are enaged in providing abortion care services.
Table 5.1 Qualifications of His by characteristics of ACFs
Ch v
Human power: Availability, strength & professional competence
87
Characteristics
of the
Institution
Urban
Rural
Public________
Private_______
_______ Regtrd
Non-Regtrd
Total
_______ Qualification of heads of institutions
Other
Gynaecs
Allopaths +
Nonnon-gynaec
(DGOs & MDs) MTP trng
allopaths
allopaths
15(21.1)
18 (25.4)
3 (4.2)
35 (49,3)
20 (45,5)
12 (27.3)
6(13.6)
6 (13,6)
Total
71 (100.0)
44 (100.0)
2 (12,5)
5 (31,3)
7(43.8) I
2(12.5) |
16 (100.0)
18(78,3)
21 (27.6)
41 (35.7)
2 (8,7)
2 (2.6)
9 (7.8)
1 (4.3)
22 (28.9)
30 (43.3)
2 (8.7)
31 (40,8)
35 (30.4)
23 (100.0)
76 (100.0)
115 (100)
2. ABORTION CARE SERVICE PROVIDERS (APs)
All those individuals mentioned by the His as abortion service providers at their ACFs were
considered for analysis of APs. These include His themselves if they were engaged in
abortion service provision. In all 121 APs were identified by His of 115 ACFs. We
interviewed 116 of them, as the rest could not be contacted.
2.1 Profile (Table 5.2): A larger number of the APs were males. More than half were
doing abortion practice for more than 11 years. Of the total APs, only a little more than
half were qualified as per the MTP Act for conducting MTP procedures. About more than
a quarter of the APs were non-allopaths. This shows that a large number of untrained APs
are engaged in providing abortion care services in the study area.
Table 5.2 Profile of abortion care providers
Characteristics of AP
Sex___________________
Male_________________
Female________________
Age (in yr)_____________
35 years or less__________
36-45 years____________
46 years and above_______
Years of abortion practice
Upto 5 years____________
6-10 years_____________
11-20 years____________
More than 20 years_______
Qualification___________
Gyneac (DGOs & MDs)
Allopath + MTP trg______
Other allopaths__________
Non-allopaths__________
N = 116
Freq
%
72
44
62,9
37.1
38
47
31
32,8
40,5
26.7
27
21
54
14
23.3
18,1
46,6
12.1
50
11
23
32
43.1
9,5
19,8
27.6
Ch V
Human power: Availability, strength & professional competence
88
2.2 Service contracts (Table 5.3): As explained initially in the chapter, we could identify
158 service contracts formed by 116 APs. An individual service provider forming a
service link also means her/his services are sought by others.
The majority (60.1%) of the providers forming the service contracts is owner-doctors. In
general, not too many were regular employees at ACFs. A little more than quarter were
providing services either on call or were attached to ACFs. Employment status of the
abortion service providers, therefore, indicates that the trend is 'not to be dependent ’ on
other providers unless required in case of emergency.
It was also examined as to who (which characteristics of the APs) are better sought than
the others. The data show that (Table 5.4) more of the male providers compared to
females serve more than one ACF. The gynaecologists were the most sought (58 %)
abortion service providers compared to other providers. Suprisingly, even the services of
non-allopaths were sought, though a meagre percentage.
Table 5.3 Profile of APs constituting the service contracts
Characteristics of AP
Freq
%
% formation of the
constituting service contracts
service contracts*
Sex____________________
Male___________________
105
66,5
45.8
Female_________________
53
33.5
20.5
Qualification_____________
Gyneac (DGOs & MPs)_____
79
50,0
58.0
Allopath + MTP trg________
13
8,2
18,2
Other allopaths____________
32
20.3
28,1
Non-allopaths____________
34
21.5
6.3
Employment status________
HI as AP________________
95
60.1
NA
Regular employee__________
7
4,4
NA
Attached________________
7,0
11
NA
On call_________________
31
19.7
NA
Spouse/son/dr-in-law_______
14
8.8
NA
N = 158 service contracts
♦Calculated using percentage of difference between number of service contracts and APs in
respective categories
2.3 Service contracts by characteristics of ACFs (Table 5.4): In general, the patterns
across these three analytical categories are consistent with the earlier ones. In that,
larger proportion of the urban based ACFs; larger proportion of the private ACFs; and
larger proportion of the private R-ACFs than their respective counter categories are
supported by appropriately qualified APs. For instance, three quarters of the service
contracts with the private R-ACFs were constituted by gynaecologists. Of the total service
contracts with private NR-ACFs, about fifty per cent was constituted by non-qualified
abortion service providers. The majority of non-qualifieds (non-gynaecologist allopaths
and non-allopaths) APs are with NR-ACFs. Neither the public ACFs engaged in abortion
care service provision nor the registered ACFs are free from service provision by non
qualified abortion service providers.
Ch V
Human power: Availability, strength & professional competence
89
Table 5.4 Qualification of APs forming service links by
characteristics of ACFs
Characteristics
of the ACFs
Qualification of APs constituting service contracts
Gynaecs
Allopaths +
(DGOs & MDs) MTP trng
Other
non-gynaec
allopaths
17(18,3)
15(23.1)
Non
allopaths
Total
18(19.4)
16 (24.6)
93(100.)
65 (100)
Urban
Rural
54 (58,1)
25 (38.5)
4 (4.3)
9(13,8)
Public________
Private_______
_______ Regtrd
Non-Regtrd
Total
6(27.3) |
8 (36,4)
6(27.3) I
2 (9.1)
22(100)
22 (75.9)
51 (47,7)
79 (50.0)
3 (10,34)
2(1.9)
13 (8.2)
1 (3-5)
25 (23,4)
3 (10.3)
29(27,1)
34 (21.5)
29 (100)
107(100)
158(100)
32 (20.3)
2.4 Abortion service support by other than His (Table 5.5): About 82.6 per cent
(95/115) of the total ACFs were self supported as regards abortion care services. This
clearly indicates indulgence of untrained APs, either allopaths and/or non-allopaths, in
abortion care service provision. This is because as seen earlier only 43.5 per cent of the
His were qualified to provide abortion care services. (Table 5.1). Of those self supported,
about three quarters did not seek abortion services from anybody and about a quarter did
seek abortion services from others in addition. At the rest, where HI did not provide
abortion care, 70 per cent of the ACFs sought abortion service from at least one AP. Of
the 72 institutions which were not supported by any additional APs other than HI, 28
(38.9 %) did not have either consultants or referral system to fall back upon; in case of
another 28, consultants were invited and the rest 16 institutions (22.2%) reported to have
referral system to fall back upon.
Table 5.5 APs other than His
Whether HI
Number of APs other than His
provides abortion
services at his own
One
Two
Three
No
ACF
Additional AP
72 (75.8)
______ Yes______ 13(13,7)
6 (6.3)
4 (4.2)
14 (70,0)
6 (30,0)
No
27 (23.5)
12 (10.4)
4 (3.5)
72 (62.6)
Total
Total
number of
ACF
95 (100.0)
20 (100.0)
115 (100.0)
2.5 Abortion service support sought by characteristic of ACFs ( Table 5.6)
The analysis of service contracts/links enhances understanding of the entire range of
professional competence as regards abortion care service providers that was available
through these ACFs. But it does not tell us availability of qualified abortion providers at
a particular ACF. For this, the unit of analysis was shifted from 'service contract" to
Ch V
Human power: Availability, strength & professional competence
90
'ACF'. From among the multiple service providers at a particular ACF, the one with
highest qualification was considered for this analysis2.
As seen earlier (Table 5.5), not all ACFs were supported by APs by other than His.
Analysis of qualifications of such APs across that of His would help us understand as to
who seeks such support and what level of professional competence is sought by them.
Data show that higher the qualification of His, less is the need for them to depend on
such contractual services. (Table 5.6). The majority of the ACFs headed by
gynaecologists, thus is self-reliant and appears to be logical. However, tendency of being
self reliant of His who are not qualifide for providing abortion services, at least in legal
sense is worrisome. This, therefore, requires further exploration. The ACFs whose heads
are not engaged in abortion service provision seem to be depending upon
outsiders/contractual services but not necessarily upon qualified APs in a stricter sense.
This also needs a further exploration.
Table 5.6 Availability of qualified abortion service support:
Abortion service support from outside
Qualification of
Heads of
institutions
Total
Qualification of an abortion provider*
Gynaecs
Allopaths
(DGOs & MDs) + MTP trng
APs_____________________
7(17.1)
~
Other
allopaths
No
outside
Non-allopaths
34 (82.9)
41 (35.7)
7 (77.8)
1(11.1)
Allopaths +
l(H.l)
MTP tmg
15 (75.0)
1 (5.0)
3 (15.0)
1 (5.0)
Other allopaths
16 (64.0)
3
(12.0)
3
(12.0)
3 (12.0)
Non-allopaths
2 (10.0)
3 (15.0)
2 (10.0)
13 (65.0)
Heads (HI) are
not abortion
providers (AP)
72 (62,6)
6 (5,2)
7(6,1)
3 (2,6)
27 (23,5)
Total________________
_____________________________________________
9 (7.8)
Gynaecs (DGOs
& MPs)_______
20 (17.4)
25 (21.7)
20 (17.4)
115(100)
*From among the multiple service providers with a particular ACF, the one with highest qualification is considered here. Heads
of the institutions who were providing abortion care were excluded from ‘multiple service providers’ (Q_aaptop)
2.6 Availability of qualified APs by characteristics of ACFs (Table 5.7):
To understand as to how many ACFs were equipped with qualified APs regardless of their
status as HI, analysis at the level of ACFs was done. From among the multiple APs at a
particular ACF, the one with highest qualification was considered for this analysis .
Though the majority (61.7%) of the ACFs has at least one qualified AP, a substantial
number (38.3%) was supported only by non-qualifides (non-gynaec allopaths and nonallopaths) APs. More of the urban based ACFs seem to be better supported than that of
rural based. Of the private registered ACFs, a large majority is supported by qualified APs.
2 This is a little liberal way of analysing the institutions as regards professional competence that they are equipped
with. This is because the underlying assumption is that all the clients ot a particular institutions are attended to by the
one with the highest qualification from among the multiple service providers, which may or may not be true. ‘Multiple
service providers’ do not include heads of institutions who were providing abortion care.
3 ‘Multiple service providers’ also include heads of institutions who were providing abortion care.
91
Ch V
Human power: Availability, strength & professional competence
Abundance of non-qualifide providers in the private non-registered ACFs is more than
clear. A substantial number of the public ACFs is not supported by qualified APs.
These trends raise a lot of questions regarding the MTP registration procedure and also
about the quality of post MTP registration monitoring mechanism that exists today. It
also reflects on poor compliance on part of His. A large number of non-registered ACFs
are supported by qualifide APs (gynaecs and MTP trained allopaths). This requires us to
understand the reasons behind they running the risk of not registering their institutions
despite meeting at least one of the major legal requirements in terms of qualifications of
abortion providers. This certainly requires, in addition to the need to look into
implementation of the MTP Act, an analysis of attitudes of heads of institutions towards
medical legislation, social accountability and also an overall awareness level. Besides, the
economics of individual health care institutions also needs to be looked into to explore the
relationship between non-registered status of a particular ACF and enhanced profit
margins, if exists any.
Table 5.7 Availability of qualified APs by charactei istictt of ACFs
Qualifications of AP*
Characteristi
cs of ACFs
Urban
Rural
Gynaecs
(DGOs & MPs
45 (63.4)
16 (36,4)
Allopaths +
MTP trng
3 (4.2)
7(15.9)
Other
allopaths
14 (19.7)
9 (20.5)
Nonallopaths
9 (12.7)
12 (27.3)
Total
71 (100,0)
44(100.0)
1(6.3) |
16 (100.0)
6 (37,5)
3(18.8) I
6 (37.5)
Public
Private_____
2 (8.7)
23 (100,0)
2 (8.7)
19 (82,6)
______ Regtrd
18(23,7)
76 (100.0)
17
(22,4)
2
(2.6)
39
(51.3)
Non-Regtrd
115 (100)
23 (20.0)
21 (18.3)
61 (53.0)
10 (8.7)
Total_______ __________________________
•From among various service contracts with a particular institution including heads of institution providing abortion
care (Q-aphtop), the one with the highest qualification is considered for this analysis.
3. CONSULTANTS AND REFERRAL: BACK-UP IN ABORTION
CARE EMERGENCIES
Generally, seeking consultants’ services and relying on referral are the ways to deal with
emergencies. The situations arise because a particular health care facility may not be in
position at times to attend to the health care needs with the help of given resources, both
in terms of professional competence of the service providers and various infrastructural
facilities. For any health care facility it is advisable to have consultants and referral system
in place to fall back upon in case of emergencies.
In abortion care, the significance is also because a large number of ACFs are found to be
ill-equipped as regards minimum physical standards and professional competence of
abortion service providers thereby potentially increasing the chances of situations requiring
such a support structure or back-up system.
Our data show that about 40 per cent of the ACFs invited consultants and about^O per
cent had some referral system in place. About 40 per cent of ACFs did not invite either
Ch V
Human power: Availability, strength & professional competence
92
consultants or had any referral system in place. (Table 5.8). Almost about half (52.1%) of
the urban based ACFs invited consultants rather than depend on the referral system. The
trend is reverse in case of rural based ACFs. This is logical because rural based ACFs will
have less scope to depend upon consultants. Proportion of public ACFs inviting
consultants and having referral system was higher than the respective proportion of private
ACFs. As we are aware the referral system in public health care sector is set and is much
better compared to that prevail in the private health care sector. However, there existed,
though a comparatively smaller number, public ACFs without either of these back-up
services. Compared to private R-ACFs, a larger proportion of private NR-ACFs relied
upon consultants’ services in case of emergencies and had referral system in place. The
explanation could be in terms of better supported R-ACF by adequately and appropriately
trained APs that we discussed earlier in this chapter.
The trends in general are reverse over urban/rural; private/public and registered/nonregistered than that were exhibited till now on other aspects of quality of abortion care.
Table 5.8 Type of back-up in abortion emergencies by characteristics of ACFs
Type of back-up available in case of emergencies in abortion care
Characteristi
cs of the
Total
None
ACT
Consultants
Referral
29
(40,8)
71
(100.0)
37 (52,1)
5(7,0)
Urban_____
17(38,6)
44 (100.0)
9 (20,5)
18(40,9)
Rural
Public_____
Private____
____ Regtrd
Non-Regtrd
Total
7(43,8)
5(31.3)
4(25,0)
16 (100.0)
6(26,1)
33 (43,4)
46 (40.0)
1 (4.3)
17(22,4)
23 (20.0)
16 (69.6)
26 (34,2)
46 (40.0)
23 (33,9)
76 (66,1)
115 (100.0)
4. ANAESTHETISTS
Services of a technically competent anaesthetist during the first trimester abortion care are
critical to the safety of women undergoing abortion. It is also a legal requirement as per
the MTP Act. Second trimester abortion care does not require anaesthesia to be
administered. Clinical studies on adequacy and safety of local anesthesia (LA) and general
anaesthesia (GA) for abortion procedures have shown that the former is adequate and safe
for the first trimester abortion procedures, (ref...). With some exceptions, it is advised that
general anaesthesia should not be administered as it involves much higher risks compared
to LA. These studies concluded that LA in combination with sedatives is sufficient during
the first trimester abortion care. In Indian context, the hospital based studies have shown
that providers prefer GA over the LA. (ref..). The often quoted reasons by the providers is
that it is easier for them to deal with the woman and the procedure. Further, according to
them it cause less or no trouble to women. However, it means more business to them as
woman has to pay more for anaesthetic services and also in most of the cases she may
have to stay overnight at the institution. The recent studies indicate declining use of GA
(ref..). It is, therefore, clear that unnecessary use of GA during the first trimester abortion
care is irrational and unethical practice, too. Women are unnecessarily exposed to higher
Ch V
Human power: Availability, strength & professional competence
93
risks and also are forced to bear unnecessary expenses towards abortion care that she
receives.
Anaesthetists are available either in-house constituting the regular staff or may provide
services ‘on call’ basis depending upon the load of surgical procedures requiring such
services. Anaesthetists’ services are involves substantial fees the reasons of the expertise
required and risks involved.
4.1 Profile (Table 5.9): Only 30 anaesthetists were identified during the survey. Males
clearly dominated anaesthetic services. Though the majority was qualified, non-qualifieds
were not absent. And the latter were from Indian Systems of Medicines.
Table 5.9 Profile of anaesthetists
Characteristics_________
Sex____________________
Male___________________
Female_________________
Qualifications___________
MD Anaesthesia__________
MBBS, Dipl in anaesthesia
BAMS + Anaesthesia course
DASF__________________
BAM&S________________
Frequency
21 (70.0)
9 (30.0)
13 (43,3)
13 (43,3)
1 (3.3)
1(3.3)
2(6.6)
N = 30
4.2 Service contracts (SCs) (Table 5.10): Anaesthetists also formed multiple service
contracts. The thirty anesthetist formed 172 service contracts with 71 ACFs giving an
average of 2.4 anaesthetists per ACF. Thirteen allopaths with diplomas in anaesthesia
constituted the majority of (60 %) of SCs. Thirteen of post graduate anaesthetists
constituted another substantial number (36.6%) of SCs. The four unqualified indulging
into anaesthesia services did not seem to be in demand as they exhibited no additional
service contracts.
The average number of service support links show that it is clearly skewed in favour of
urban based ACFs; of private based ACFs. Thus, the differentials are more sharp on
account of location and type of ACFs. It is slightly more for NR-ACFs compared to RACFs.
Ch V
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94
Table 5.10 Qualification of anaesthetists constituting service contracts by
characteristics of ACF
Characteristics
of the Institution
Urban
Rural
Public_______
Private_______
_______ Regtrd
Non-Regtrd
Total_________
Qualification of anaesthetists constituting service contracts
Average*
Anaesthetists Anaesthetists Non-allopath+ Non-allopaths Total
(MDs)
(MBBS+
course in
(DASF/BAMS/
anaesthesia
BAM&S)
diploma)
2,6
145 (100.0)
3(2.1)
91 (62,8)
51 (35.2)
1.6
27
(100.0)
1 (3.7)
13(48,1)
12 (44,4)
1 (3-7)
4(33,3) |
7 (58,3)
1(8,3) |
12(100.0)
1.7
2.2
47 (100.0)
27 (57.5)
20 (42.6)
2.5
113(100.0)
3 (2.7)
70 (61,9)
1 (0-9)
39 (34,5)
2.4
172 (100)
4 (2.4)
1 (0.6)
104 (60.5),
63 (36.6)
,
, .____
___________
____________
* Average SC constituted by anaesthetists. These exclude 44 ACFs which were not supported by any anaesthetist. Eg.
Of the 71 total urban based ACFs, only 55 which were supported were counted while amving at averages.
4.3.a Service support by anaesthetists (Table 5.11): The 30 anaesthetists were meeting
needs regarding anaesthetics services of 71 of 115 institutions from the study area. The
resT44 {38.3%) ACFs did not have these services. It is to be noted that except one, all the
ACFs from the sample offered first trimester abortion services which require ACFs to be
equipped with these services. The risks involved on account of non-qualified in these
services are life threatening and fatal. Against this backdrop then, about 12.12 per cent of
non-qualifieds engaged in these services is a distressing situation.
A considerable number of institutions had more than one anaesthetists which is mostly
because of the very specific nature of these services (Table 5.11). The advantage of
multiple anaesthetists being linked to a particular ACF are obvious given the nature of
their Con-call’ nature of services. Multiplicity enhances their availability when required.
Thus, it reduces chances either of women being denied abortion care services or of women
having to take the trouble of making another visit. Or else they are exposed to unsafe
abortion care in absence of qualified anaesthetist in situations of such requirement.
Table 5.11 Service support by anaesthetists
Number of Anaesthetists
Self__________________
One__________________
Two____________ _____
Three________________
4 & more___________ __
No anaesthetist_________
Freq & %
1 (0-8)
25 (21,7)
19(16.5)
11 (9.6)
15 (13.4)
44 (38,3)
N=115
4.3.b Availability of technically competent anaesthetists by characteristics of ACFs
(Table 5.12): To understand as to how many ACFs were equipped with qualified
anaesthetist/s, analysis at the level of ACFs was done. From among the^ multiple
the one with highest
anaesthetists providing services at a particular health care facility,
f
qualification was considered for this analysis.
Ch V
Human power: Availability, strength & professional competence
95
Of total urban based ACFs, the majority (J4.6%) was supported by qualified anaesthetists’
services. Of the total rural based ACFs, only 36.4 per cent were equipped with these
services. Of the total ACFs without anaesthetists’ services, the rural based ACFs
constitute the majority (63.6%, 28 of 44). Except a small number (8.7%), a large majority
of the private R-ACFs were supported by qualified anaesthetists. The private NR-ACFs
had a major share (75%, that is 33 of 44) among those not having these services.
However, a little moreThan half of them were supported by qualified anaesffietistsTOfthe^'
total public ACFs, only 37.5 per cent were supported by qualified anaesthetists while 62.6
per cent (62/99) of the private ACFs were supported by these services.
The differentials across the analytical categories exhibit similar trends as observed
earlier. The urban based ACFs are better placed. Not all public ACFs were supported by
these essential services. Not all NR-ACFs were ill-equipped as regards anaesthetists.
Table 5.12 Availability of qualified anaesthetists by characteristics of ACFs
Characteristi
cs of the
ACFs
Urban
Rural
Total
Qualifications of anaesthetists*
Anaesthetist with
MPs &/or Diploma
53 (74.6)
15(34.1)
Not qualified
(DASF & BAM&S)
________ 2 (2.8)
________ 1 (2-3)
No anaesthetist
16 (22,5)
28 (63.6)
71 (100.0)
44 (100,0)
16 (100.0)
9 (56.3)
6 (37,5)
Public_____
1 (6.3)
Private____
2 (8.7)
23 (100.0)
21 (91.3)
_____ Regtrd
76 (100.0)
2 (2.6)
33 (43.4)
41 (53,9)
Non-Regtrd
44 (38.3)
115 (100.0)
3 (2.6)
68 (59.1)
Total______
*From among various service contracts with a particular institution of anaesthetists, the one with the
highest qualification is considered for this analysis.
5. LABORATORY TECHNICIANS (in-house)
Service provision by in-house laboratory technician (LT) are not essential at ACF either
legally or medically. However, from women’s pespective, these services being in-house is
of significance.
5.1 Profile (Table 5.13): There were 47 laboratory technicians who provided pathology
services to 41 of the 115 ACFs. The majority of them were males. A large majority
(72.3%) of the LTs were diploma holders. Non-qualified constituted a considerable
number.
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Human power: Availability, strength & professional competence
96
Table 5.13 Profile of Laboratory technicians
Characteristics__________
Sex___________________
Male__________________
Female________________
Qualifications___________
Degree in lab tech________
Diploma in lab tech_______
Certificate in lab tech_____
In-house training/expereince
Non-qualified___________
No information__________
N = 47
Freq
%
29
18
61.7
38.3
1
34
1
3
7
1
2.1
72.3
2.1
6,4
14,9
2.1
5.2 Availability of qualified LTs by characteristics of ACFs (Table 5.13): Not all
ACFs were supported by services of laboratory technician. A large number (64.4%) of the
ACFs did not have LTs as part of their regular staff.
The pattern of availability of these services across urban/rural differs from the earlier
trends. In that, a larger proportion of the rural based ACFs are equipped with these
facilities compared to urban based ones. Availability of full-fledged patholgy laboratories
in urban areas could be one of the plausible explanations for this pattern. The pattern
across private R-ACFs and NR-ACFs is in line with the earlier ones. An overwhelming
majority of the R-ACFs was equipped with these facilities. Also, a larger number of the
public ACFs have these facilities in-house. However, not all public ACFs were in position
to have them in-house. The direct implications of these are, either women undergo
abortion procedure without providers conducting these tests or if prescribed, women have
to get them done from outside which mostly means approaching the private facilities and
paying for these tests.
Table 5.13 Availability of laboratory technicians
Characteristics
of the Institution
Urban
Rural
Whether LT is available
Yes________
23 (32,4)
18 (40.9)
Public
9 (56,3)
Private
14 (60,9)
_________ Regtrd
_____Non-Regtrd
18 (23.7)
_Total
41 (35.7)
N 115, figures in braces are the column percentages.
In-house
Total
No_________
48 (67.6)
26 (59.0)
71 (100.0)
44(100.0)
7 (43,7)
16 (100.0)
9(39,1)
58 (76,3)
74 (64.3)
23 (100,0)
76 (100.0)
115 (100.0)
Ch V
Human power: Availability, strength & professional competence
97
Of the ACFs supported by in-house services of a laboratory technician, the majority (33
of 44) had one such technician.
6. NURSES
Nursing care constitutes one of the essential services in case of abortion service provision
as stated in the Maharashtra State level Rules and Regulations. Availability of nursing care
from women’s point of view is significant.
6.1 Profile and availability: As generally is the pattern, women shouldered the
responsibility of nursing care. About 79.1 per cent of the ACFs (91 of 115) did have
nurses to attend to their clients’ nursing care needs. (Table 5.14). However, of those who
did not have nurses, the share of rural based, private ones and the private NR-ACFs were
more compared to their counterparts in urban areas, public ones and R-ACFs. All the
public ACFs were supported by nurses. Not all private R-ACFs were supported by
nursing care.
Table 5.14 Availability of nurses
Characteristics of the ACFs
Availabililty of nurses
Yes
62 (87,3)
Urban
Rural
29 (66,0)
No_______
9 (12,7)
15 (34.0)
16(100,0)
Public
Private
Regtrd
Non-Regtrd
21 (91,3)
54 (71,1)
JTotal
91 (79.1)
N 115, figures in braces are the column percentages.
Total
71 (100.0)
44 (100.0)
16 (100,0)
2 (8,7)
22 (28,9)
24 (20.9)
23 (100,0)
76 (100,0)
115 (100.0)
Ninety one of the 115 ACFs (as 24 ACFs did not have any nurses) were supported by
367 nurses. (Table 5.15(a)). That gives an average of 4 nurses per ACFs.
6.2. Qualifications/training: As anticipated about half (52.9%) of the total nursing staff
has acquired training in-house. Such in-house trained nurses were employed at about
more than half of the ACFs. (Table 5.15(a)). The rest of the professionally trained nursing
staff from each category supported comparatively small number of ACFs, for instance, 49
qualified nurses supported only 15 ACFs.
The listed certificate courses were mostly private run. Most of the ACFs in Baramati tehsil
had nurses who completed ‘certificate courses’ in nursing. This atypical trend could
attribute to the nursing training institution that exists in Baramati.
Ch V
Human power: Availability, strength & professional competence
98
Table 5.15(a) Type of training of nurses
Type of training of nursing staff
Number & % of
Nurses
Degree holders
Diploma holders
Certificate holders
In-house trained
49 (13,4)
41 (11.2)
83 (22,6)
194 (52,9)
367 (100.0)
Total
* Not mutually exclusive.
ACFs at which nurses were
______ employed*______
______________ 15 (13.0)
_____________ 12(10.4)
____________ 28_(24,4)
______________ 61_(53.0)
_____________
115
Of the 15 ACFs having degree holder nursing staff, two third were urban based; and one
third private R-ACFs was supported by degree holder nurse (Table 5.15(b)). These also
tend to be large (in terms of number of beds) set ups. Diploma holders do not seem to
exhibit any sinking pattern as regards characteristics of ACFs at which they are employed
Certificate holders are more at urban based ACFs and are in private sector.
Table 5.15(b) Formally qualified nurses by characteristics of ACFs
Characteristics of the
institutions
Number of ACFs with
degree
holders
Rural/Urban
Urban______
Rural
Public/private
Public_______
Private
I
Registered
Non-Registered
Size (Number of beds)
5 or less beds________
6-15 beds___________
16-25 beds__________
26 or more beds
diploma
holders
10
5
6
6
21
7
10
5
7
2
5
5
4
16
2
4
2
19
6
3
3
5
2
15
12
28
2
7
Total
certificate
holders
6.3 Availability of professionally trained nursing care by characteristics of ACFs:
We further analysed as to the extent to which the ACFs were supported by formally
qualified nursing care service providers. (Table 5.15(c)). As anticipated, as large as 60 per
cent of ACFs had no single formally trained (degree/ diploma/ certificate) nurse.
Proportions of ACFs with at least one qualified nursing staff shows an ascending trend
along the increasing number of beds at ACFs, indicating a positive association with size of
the ACFs. Larger set ups seem more likely to have qualified nursing staff. In general, the
Ch V
Human power: Availability, strength & professional competence
99
pattern is consistent with the earlier ones in that urban based, and private R-ACFs are
better placed than their counterparts The distinct fontnre is that \\U the public ACFs were
supported by at least one qualified nurse.
Table 5.15(c) Availability of qualified nurses by characteristics of ACFs
Number of ACFs with
Characteristics of
the ACF
Urban
Rural
Public
Private
__________ Regtrd
______ Non-Regtrd
Total
At least one
qualified nurse
________ 32 (45.1)
14 (31.8)
No qualified
Nurse_____
______ 39 (54.9)
30 (68.2)
46 (40.0)
71 (100.0)
44 (100.0)
16 (100.0)
16(100,0)
8 (34.8)
22 (28,9)
Total
15 (68.5)
54 (71,1)
69 (60.0)
23 (100,0)
76 (100.0)
115 (100.00
7. AAYAS AND WARD BOYS
These constitute the complementary services at ACFs and are important from woman’s
point of view. Our data show that not all ACFs were supported by these services. (Table
5.16).
7.1 Aayas: The majority (75.7%) of the ACFs were supported by services of aayas. About
236 aayas supported 87 ACFs giving an average of 2.7 aayas per ACF. Among those
ACFs which did not have, like in other cases, the rural based were more in number
compared to the urban based. Not all the public ACFs were supported by these services.
This perhaps could be explained with the fact that all the public ACFs were equipped with
nurses unlike private ACFs. All the private R-ACFs had aayas to serve the users. The
majority (69.7%) of the NR-ACFs too had aayas. It appears that in the private ACFs,
lack of availability of trained nursing care is compensated by services of aayas.
7.2 Ward-boys: A large number of ACFs (41.7 %) did not have ward-boys. Of the total,
67 ACFs had 169 wardboys giving an average of 2.5 per ACF. Proportion of urban ACFs
without ward boys was much higher than proportion of the rural based ACFs. The
majority of the public ACFs (81.3%) had ward boys. The private NR-ACFs were slightly
better place compared to R-ACFs.
7.3 Enquiry attendant: More than half (56.8%) of even the rural based ACFs had a
person to attend to the enquiries of the clients. All public ACFs were not equipped with
an enquiry attendant. Proportion of the private R-ACFs was more than NR-ACFs as
regards these services. We, however, would like to record here that enquiry attendants
were with multiple Job responsibilities and were not with the sole task of attending to
clients' enquiries.
Ch V
Human power: Availability, strength & professional competence
100
Table 5.16 Availability of aayas, ward boys and attendant
Characteristics
of the ACFs
Availablility of
Urban
Rural
Aayas
Yes
59 (83.1)
28 (63,4)
No
12 (16,9)
16 (36,4)
Wardboys
Yes
36 (50.7)
31 (70.5)
No
35 (49,3)
13 (29.5)
Public
11 (68.8)
5(31.3) |
13(81.3) |
3(18.8)
23 (100.)
53 (69,7)
87(75.7)
23 (30,3)
28 (24.3)
11 (47,8)
43 (56.6)
67(58.3)
12 (52.2)
33 (43.4)
48 (41.7)
Private
Regtrd
____ Non-Regtrd
Total
~
Total
|
Enquiry attendant
Yes ________ No
47 (66,2)
24 (33,8)
25 (56,8)
19 (43.2)
71 (100.0)
44 (100,0)
8(50.0) |
8(50.0)
16 (100.0)
18 (78,3)
46 (60.5)
72 (62.6)
5 (21,7)
30 (39.5)
43 (37.4)
23 (100,0)
76 (100,0)
115 (100.)
5.7.4 The extent to which ACFs are equipped with all the three services providers,
nurses, aayas and ward boys (Table 5.17): Not all ACFs were supported by these
servtces. There were at least 4 ACFs, which did not have either of these staff employed
All of them were pnvate NR-ACFs. And 3 of the 4 were rural based. Also they were with
ess number of beds. Further, analysis across the three basic analytical categories shows
registeredtrendS
°f ACFS
baSed’ PUbUc °neS and the
Ch V
Human power: Availability, strength & professional competence
101
Table 5.17 Support services of nurses, aayas and ward boys by characteristics of
health care institution
Service support of nurses, aayas and ward boys
Characteristics
of the
Institution
None
Urban
Rural
1(1-4)
3 (6.8)
Nurse/s &
aaya/s &
wb/s
27 (38.0)
15 (34,1)
Nurse/s alone
or with
______ wb or aaya**
35 (49,3)
8(11.3)
14(31.8)
12(27.3)
No nurses*
9 (56,3)
7(43.8) |
Public_________
Private________
10(43,5)
11 (47,8)
2 (8,7)
_________ Regtrd
23
(30,3)
31 (40,8)
18(23.7)
4(5.3)
Non-Regtrd
15 (34.1)
49 (42.6)
20 (17.4)
4 (3.5)
Total_____________
* These either were with only ward boys or only aayas or both together but no nurses
** These either were with only nurse, or nurse & aaya, or nurse & ward boy.
Total
71 (100.0)
44 (100.0)
16 (100.0)
23 (100.0)
76 (100.0)
115 (100.0)
Social workers: No single ACFs offered such services.
8. PROFESSIONALLY COMPETENT SERVICE PROVIDER OF ESSENTIAL
SERVICES: A COMPOSITE ANALYSIS
For a health care facility to be able to provide safe and legal abortion services to women, it
is essential that it is supported by a qualified abortion service providers. Till now, ACFs as
regards availability of qualified human power, were assessed independently for each type
of service providers. This does not tell us the extent to which a particular ACF, at a time,
is equipped with all essential service providers with required and legally stipulated
professional competence. ACFs, therefore, are assessed for simultaneous availability of
qualified abortion service providers and anaesthetist.
The data show that only 53 institutions are supported by both, the qualified abortion
provider/s and qualifed anaesthetist/s. (Table 5.18(a)). Of the total, 29 ACFs do not have
either a qualified abortion service provider or a qualified anaesthetist.
Table 5.18(a) Availability of qualified abortion service providers and anaesthetists
Qualification of abortion
provider"
Total
Qualification of anaethetist**
Not qualified
anaesthetist
(MDs &Diploma) (DASF & BAM&S)
1
49
0.9
42.6*
1
4
0.9
3.5
11
9.6
1
4
0.9
3.5
3
68
2.6
59.1
No
Anaesthetist
Gynaecs (DGOs & MDs)
Allopaths + MTP tmg
Non-gynaec allopaths
Non-allopaths
Total
11
9.6
5
4.3
12
10.4
16
13.9
44
38.3
61
53.0
10
8.7
23
20.0
21
18.3
115
100.0
N = 115
* From among multiple abortion service providers, including heads of institution providing aboriton care, the one
with the highest qualification (Q_aphtop) is considered for this analysis.
♦♦ anaethetists, the one with the highest qualification (Q_antop) is considered for this analysis.
102
Ch V
Human power: Availability, strength & professional competence
. r
( 7852
v
"s t
--s
A/
Only about 57.7 per cent of the urban based ACFs are equipped both with a qualified
abortion service providers and a qualified anaesthetist. (Table 5.18(b)). Three quarters of
the public ACFs are not equipped with these two essential services simultaneously. A
large majority (82.6%) of the private R-ACFs are equipped with these two essential
services at a time. Of the total private NR-ACFs, two fifths are equipped with these
services. Larger ACFs tend to be better equipped with these two essential services.
In general, the trends across urban/rural; pnblic/private and registered/non-registered
are in line 'with those seen in case of various other structural aspects of quality of care.
Ill-supported public ACFs and private R-ACFs and reinforces the two arguments, among
others, those emerged from the data trends. One, the registered status of a particular ACF
does not ensure safe abortion and not all public health care facilities engaged in abortion
care necessarily meet all the legal requirements. Two, not all non-registered ACFs are
unsafe as regards abortion care services. Consequently, it also confirms the issues that
were discussed from time to time in earlier part of the report about medical fraternity’s
low compliance and poor monitoring of the legislative measure by the state administrators,
in general.
Table 5..18(b) Characteristics of ACFs equipped with Qualified abortion service
providers and anaesthetists
Characteristics of the ACFs
Number of ACFs with
Qualified APs
& AN
Urban
Rural
41 (57.7)
12(27.3)
Non-qualified
AP&AN or
no services
30 (42,3)
32 (72.7)
Public
4 (25,0)
12 (75.0)
16(100.0)
19 (82,6)
30 (39.5)
53 (46.1)
4(17,4)
46 (60.5)
62 (53.9)
23 (100.0)
76 (100,0)
115 (100.0)
Total
71 (100,0)
44 (100,0)
Private
Registered
Non-Registered
Total
9. SUMMARY & CONCLUSIONS
Providers of essential services
■
Only a little more than a half of the APs were qualified. More than a quarter
were untrained (for abortion procedures) non-allopaths and about one fifth were
untrained allopaths.
■
About two fifths (38.3%) of the ACFs did not have a single qualified AP About
one fifth of the ACFs were served only by untrained non-allopaths. A little more than
two fifth of the public ACFs did not have a single qualified AP. Except a small
percentage (8.7) all the private R-ACFs were served by qualified AP. About a half of
the NR-ACFs were served by a qualified AP.
Ch V
Human power: Availability, strength & professional competence
103
■
In all, 30 anaesthetists supported 71 ACFs. Four of the 30 were non-qualified
anaesthetists.
■
About two fifth (38.3%) of the ACFs were not at all supported by anaesthetists.
A little more than a half of the public ACFs were not supported by any anaesthetist’s
services. A large majority of about four fifth of the private R-ACFs were equipped
with anaesthetist’s services. About more than a half of the private NR-ACFs were
supported with anaesthetist/s.
■
Only 53 per cent of the ACFs were equipped simultaneously with the essential
qualified service providers, both APs and ANs. About three quarters of the public
ACFs were not equipped with these essential service providers comprehensively. An
overwhelming majority of about more than four fifth of the private R-ACFs were
supported by essential service providers. About two fifth fo NR-ACFs were also
supported simultaneously by these essential service providers.
■
It once again proves that neither the public ACFs nor the private R-ACFs comply
with the MTP Act as regards stipulated qualifications of essential services such
as abortion provider and anaesthetist.
■
At the same, it again proves that not all NR-ACFs are unsafe as regards abortion
service provision.
Providers of complementary services
■
In all 47 LTs supported 41 ACFs. Of these the majority (70.3%) were diploma
holders.
■
The majority (64.3%) of the ACFs did not have in-house services by laboratory
technicians. About two fifth (43.7%) of the public ACFs were lacking such in-house
services. About three fifth of the private R-ACFs were equipped with these services in
house.
■
About half (52.9%) of the nursing staff was trained only in-house. About 13.4
per cent were degree holders; 11.2 per cent were diploma holders and 22.6 per
cent were certificate holders.
■
About three fifth of the ACFs did not have a single formally trained nurse. And
About one fifth (20.9%) of the ACFs were without any nursing care services. All
the public ACFs were equipped with at least one trained nurse. Only about one third of
the R-ACFs had nursing care available by professionally trained one. About one third
of the NR-ACFs were equipped with such nursing care.
e
About a quarter of the ACFs did not have any aayas. Only about three fifth ACFs had
wardboys.
■
Thus, a substantial number of ACFs are poorly equipped as regards essential
service providers as well as complementary service providers.
Ch V
Human power: Availability, strength & professional competence
104
Table 6.2 Availability of qualified abortion senice providers and all the minimum required
life saving drugs
Qualification of abortion
provider *
Availability of life saving /emergency
drugs**
Completely***
stocked
Partially
stocked
Total
Lack of
life saving
drugs
Gynaecologists (MDs & DGOs)
44 (72,1)
17 (27,9)
61 (100,0)
Allopaths + MTP tmg________
4 (40.0)
6 (60,0)
10(100.0)
Non-gynaec allopaths_________
13 (56,5)
9(39,1)
23 (100,0)
1 (4.3)
Non-allopaths________________
8(38,1)
11(52.4)
21 (100.0)
2 (9.5)
Total______________________ _
69 (60.0)
43 (37.4)
_________
3 (2.6)
115 (100)
*From among various service contracts with a particular institution including heads of institution
providing abortion care (Q-aphtop), the one with the highest qualification is considered for this analysis.
** Nine drugs were listed as life saving/emergency drugs.
***ACFs with all 9 of them are coded as ‘Completely stocked’;
with less than 9 of them are coded as ‘partially stocked’ &
with no drugs are coded as ‘lack of life saving drugs’.
2. PHYSICAL STANDARDS AND HUMAN POWER:
ANAESTHETISTS’ SERVICES
Availability of qualified anaesthetist and complete set of the instruments/equipment
required for anaesthesist services (Table 6.3): Such a comprehensive assessment shows
that 26 of 115 ACFs meet these requirements and thus are comprehensively equipped for
anaesthetist services.
Table 6.3 Availability of qualified anaesthetist and complete set of
instruments/equipment for administering anaesthesia
Qualification of anaesthetist
Availability of essential equipment for
anaesthesia and resuscitation*
Total
Completely**
equipped
26 (38.2)
Partially
Lack of
No
equipped
equipment
Infn
Qualified (MDs & Diploma)
42 (61,8)
68 (100,0)
Not qualified (DASF & BAM&S)
3 (100,0)
3 (100,0)
No anaesthetist_______________
5(11.4)
23 (52,3)
13 (29,5)
44 (100.0)
3 (6.8)
Total__________________
31 (27.0)
68 (59.1)
13 (11.3)
3 (2.6)
115 (100.0)
♦From among various service contracts with a particular institution (Q-antop) of anaesthetists, the one with the highest
qualification is considered for this analysis.
**Six instruments/equipment were listed as minimum physical standards requirement for administering anaesthesia and/or
to meet resuscitation needs.
** "Completely equipped: ACFs with all six instruments/equipment
Partially equipped : ACFs with less than six instruments/equipment
Lack of equipment : ACFs with none of the six instruments/equipment
Ch VI
Conclusion: Structural aspects of quality ofabortion care
106
3. PHYSICAL STANDARDS AND HUMAN POWER:
A COMPREHENSIVE ASSESSMENT OF ABORTION CARE SERVICES
A particular ACF could be considered as structurally sound as regards quality of abortion
care services if it is supported simultaneously by at least one qualified AP, a qualified
anaesthetist and is equipped with complete sets of instruments/equipment for abortion
procedure, for administering anaesthesia and all the minimum required life saving drugs.
Such a comprehensive assessment (Table 6.4 (a) and alternatively 6.4(b)) shows only a
meagre number of 13 of 115, (11.3 %) are equipped for providing abortion care services.
In a stricter sense, only these many are in position to offer safe abortion care services.
The trend of urban based ACFs being better than rural ones and R-ACFs than NR-ACFs
continues. Of the public ACFs only one is equipped to provide safe abortion care. (Table
6.5).
Table 6.4(a) Physical standards and human power: A comprehensive assessment
Qualification
of abortion
provider
Gynaecs
(DGOs.& MPs)
Qualification
of
anaesthetist
Qualified*
Availability of essential equipment & life
saving/emergency drugs***
All
essentials
12 (24.5)
Three
essential
25 (51.0)
Two
essential
8(16.3)
One
essential
4 (8.2)
None
12 (19.7)
1 (100.0)
5 (45,5)
31 (50.8)
4 (36.4)
12 (19.7)
1(9.1)
5 (8.2)
1(9.1)
1(1.6)
1 (25.0)
1 (25.0)
2 (50.0)
Not qualified**
No anaesthetist
Sub-Total
Allopaths +
MTP trng
Qualified
Total
Not qualified
49 (100.0)
1 (100.0)
11 (100.0)
61 (100.0)
4 (100.0)
1 (10.0)
1 (10.0)
3 (60.0)
5 (50.0)
1
(100.0)
2 (40,0)
3 (30.0)
3 (27.3)
4 (36.4)
3 (27.3)
1(9.1)
11 (100.0)
1 (8-3)
4 (17.4)
1 (8.3)
5 (21.7)
8 (66.7)
11 (47.8)
2 (16.7)
3 (13.0)
12 (100.0)
23 (100.0)
Qualified____
1 (25.0)
Not qualified
No anaesthetist
Sub-total
________________ 1 (4.8)
Grand Total
18(15.7)
* (MDs & Diploma) ♦♦ (DASF & BAM&S)
3 (75.0)
No anaesthetist
Sub-Total
Non-gynaec
allopaths
Qualified
Not qualified
No anaesthetist
Sub-Total
Non-allopaths
1 (6.3)
4 (19.0)
41 (35.7)
Ch VI
Conclusion: Structural aspects ofquality of abortion care
1 (100.0)
5 (100.0)
10 (100.0)
4(100,0)
1 (100.0)
4 (25.0)
5 (23.8)
33 (28.7)
1 (100,0)
5(31.3)
5 (23.8)
16 (13.9)
6(37.5)
6(28.6)
7 (6.1)
16(100,0)
21 (100.0)
115 (100.0)
107
Table 6.4 (b) Physical standards and human power: A comprehensive assessment
Qualification of
abortion provider *
Qualification of
anaesthetist **
Qualified
Gynaecs (DGOs & MDs)/
Allopaths + MTP tmg
Qualified
(MDs & Diploma)
Availability of essential equipment
& life saving/emergency drugs***
all essential
Not all/none
13
40
53
18
18
13
58
71
Qualified
(MDs & Diploma)
4
11
15
Not qualified /not
available
1
28
29
5
39
44
Not qualified/not
available
Sub-Total
Not qualified
(Non-gynaec allopaths or
non-allopaths)
Total
Sub-Total
Grand Total
18|
115 |
97
Table 6.5 Characteristics of ACFs with qualified service providers and completely equipped with
minimum physical standards
Characteristics of the institutions
Rural/Urban
Urban
Rural
Public/private
Public
Private
Number of ACFs
10(76.9)
3 (23.1)
1 (7.7)
Registered
Non-Registered
Size (Number of beds)
5 or less beds
6-15 beds
16-25 beds
26 or more beds
7(53.9)
5 (38,5)
4 (30,8)
5 (38.5)
4(30.1)
N = 13
Ch VI
Conclusion: Structural aspects ofquality ofabortion care
108
Chapter VII
THE MTP ACT:
KNOWLEDGE AND PERCEPTIONS OF
THE HEADS OF INSTITUTIONS AND THE PROVIDERS
1. The MTP Registration Procedure
1.1 Efforts made and problems encountered during MTP registration
1.2 Why MTP registration was not tried for?
1.3 Suggestions and improvement
1.4 Compliance with the MTP Act
2. Content of the MTP Act
2.1. Physical standards
2.2. Qualification of abortion providers
2.3. Comparability of qualifications of provider as stipulated in the MTP Act
2.4. Minimum qualifications for the assistant doctors
2.5. Minimum qualifications for the assistant nurses
3. The MTP training facilities
3.1 Avenues to learn MTP skills
3.2 Training facilities offered by the government
3.3 The training in counselling
3.4 Prevailing MTP training facilities
4. The legal requirement of blood bank: How scientific and feasible
4.1. Availability of blood banks in the study area
4.2. The need for blood transfusion during MTP
5. Summary and conclusions
Ch- VII
The MTP Act: knowledge and perceptions of
the heads of institutions and the providers
109
Chapter VII
THE MTP ACT:
KNOWLEDGE AND PERCEPTIONS OF
THE HEADS OF INSTITUTIONS AND THE PROVIDERS
There prevails a large number of private non-registered abortion care facilities everywhere. The
findings, especially on ‘physical standards’ and ‘human power’, the structural aspects of quality
of abortion care, presented earlier in the report clearly bring out the fact that compliance on part
of the medical fraternity is extremely poor. It is therefore logical to explore with the His and
APs as to what views they hold about the legislation and what problems do they face as regards
complying with the legislative measures. Non-compliance on their part, obviously, would have
impact on women’s access to safe and legal abortion care. Perspectives of heads of the
institution and providers, therefore, assume a significance in provision of quality abortion care
services to women.
This chapter focuses on the knowledge and perceptions of the heads of the institutions and the
providers. The data, however, needs to be viewed in the larger socio-political context. As we
know, the MTP Act, in addition to specifying ‘the situations under which women could seek
abortion care’, deals with two major aspects of health care institutions: one, it talks about the
minimum physical standards in health care institutions providing MTP care; two, it stipulates
minimum qualifications for abortion providers. Besides, the complementary 'Rules and
Regulations', Maharashtra State specifies the minimum qualifications that the assistant
providers and assistant nurses must have. We, therefore, designed a set of questions (semi
structured) to administer to the His (115 respondents) about physical standards of institutions,
and, another set of questions for providers (116 respondents) about qualifications of providers,
assistant providers and assistant nurses.
The chapter presents the data on knowledge and perceptions of a) the heads of the institutions
(His) and b) the abortion service providers (APs), about different issues related to the MTP
Act. His were asked about their: awareness about the MTP Act, experiences of the registration
procedure, suggestions for improving the registration procedure, and opinions about the
minimum physical standards that are laid down in the MTP Act. Views of APs were sought on:
the minimum qualifications for abortion providers (doctors and assistant doctors), minimum
qualification for the assistant nurses, MTP training facilities with related issues, and their
experiences of the same. However, these data in isolation, without having been complemented
by facts about ground realities would not have provided the required insights. Therefore,
interviews were conducted with c) representatives of the bureaucracy and the faculty of
teaching hospitals. They have given information mainly about the MTP training facilities and
related matters. They have also talked about availability and spatial distribution pattern of the
blood banks and related matters.
Based on the analysis of data1, we arrived at some concrete recommendations for improving
women’s access to safe and legal abortion. Towards the end of the chapter, we have raised a few
issues which lie outside the limited scope of abortion care and MTP Act.
1 Descriptive responses were quantified to arrive at the figures.
Ch- VII
The MTP Act: knowledge and perceptions of
the heads of institutions and the providers
no
1. THE MTP REGISTRATION PROCEDURE
Heads of the institutions are involved in MTP registration procedures. We, therefore, elicited
the data on these issues from them and not from abortion service providers.
The public health care institutions engaged in abortion care services do not have to undergo the
registration process like the private ones do. Therefore, the 16 public health care institutions in
our sample of 115 institutions were not asked about registration. Of the remaining 99 private
institutions, 23 were registered. Of the 76 non-registered institutions. His of 28 had tried for
registration, while those of 48 had never tried for it.
1.1 Efforts made and problems encountered during MTP registration: We could elicit data
on the problems encountered during the registration process from only 51 (23 registered, and 28
that tried but could not get registration) of the total respondents.
Ten of the 23 His, who had registered, said that they did not encounter any problems. Four
mentioned that problems encountered were for the reasons of mismanagement at the
government offices and two others attributed them to corruption there. Seven of them said that
the procedure was very tedious and time consuming
Heads of 28 institutions could not register despite efforts. They mentioned various reasons for
it. (See Table 1).
Table 1: Why the institution did not get MTP registration?
_____________________ Reasons__________________
N (%)
16(57.1)
• No response from the govemment/concemed authority
4(14,3)
• Did not meet the criteria stipulated in the MTP Act
8 (28.6)
• Other (not pursued/in process/applications were not
available)____________________________________
N=28 (responses of 28 of 76 non-registered who had tried for MTP registration)
According to 16 His, the government authority was responsible for this. The concerned
authority either never responded to their applications, or the inspecting authorities never turned
up or, the application form was not available. Some also added that the concerned
authorities/offices were ill-informed and misguided them. Often, multiple reasons were given.
Some of the reasons given are quoted here:
1. '‘Have applied (for registration) but haven't yet got it. Even DHS office does not know about
it. Application forms are not available when one wants to have one. We then requested to one
of the officers there. He told us,
“ifyou register your centre for MTP, you have to offer abortion services at very low fee.
Instead, registration for FP (family planning operation) is more profitable because of the
government grants.
2. Ifyou ask (them) for MTP registration, they keep looking at each other. Not only that, they
further told us,
Ch- 17/
The MTP Act: knowledge and perceptions of
the heads of institutions and the providers
111
“since you both are qualified, (you) need not seek registration. You are qualified to conduct
MTPs”. ”
Heads of four institutions reasoned that the legal criteria for registering a centre are too stringent
and it is not practically possible to meet the conditions. These are some more responses:
3. “No (access to the) blood bank and therefore refused the registration
4. t(A sister (nurse) is required. Here, (we) don’t get the trained staff. Therefore refused (the
registration)
5. “Overall it is a serious problem... Blood bank is required. Qualified nurse is required. These
(criteria) are very problematic (to meet with). Otherwise, I do meet the physical standards (as
per the MTP Act). ...”
1.2 Why MTP registration was not tried for: Forty-eight His had never tried for registration
either because of lack of information about the registration procedure or because they knew that
their institutions did not meet the legal specifications or because they were ill-informed about
the MTP Act and related matters. (See Table 2)
Table 2: Why MTP registration was not tried for?
N (%)
_____________________ Reasons____________________
6(12,5)
• Lack of information about the registration process
11 (22.9)
• Know that the conditions stipulated in the Act would
not have been met_____________________________
9(18.8)
• Misconceptions about what is stipulated in the Act
9(18.8)
• Other________________________ _______________
13 (27,1)
• No specific reason mentioned_____________________
N=48 (responses 48 of 76 non-registered who never had tried for MTP registration and did not get it)
Those who feared that their applications would not be considered were either not qualified or
were in the government service or generally felt that they did meet the criteria stipulated in the
MTP Act. Their responses tell us that they were conscious of their illegal MTP practice:
1. “I have done a course in Homeopathy. How could!get (an MTP) registration? ”.
2. “(I am a) government employee. (My) wife is a BAMS. Registration, therefore, can’t be
(done) on my name. Now that I am gradually settling in my practice, once (I have) settled (I)
would leave government job. I, then, would seek a registration ”.
The ill-information was of a wide range:
‘small clinics do not require registration’, ‘gynaecologists do not require to seek separate
registration’, ‘recognition as family planning centre implies recognition for MTP practice’,
‘private practitioners are not allowed to conduct MTPs’, ‘such a registration is not required for
MTP practice’, ‘registration is not required for conducting MTPs for married women’,
‘registered with the Medical Council and therefore does not require MTP registration’. One
respondent says:
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112
3. "... There is no problem in case of (abortions of) marrieds. After all, it is only a minor surgery.
However, if (abortion cases are of) unmarrieds, one definitely needs to seek permission
(registration) for... ”
Of the 48 His who never tried for registration, 41 were either 'non-gynaec allopaths’ or ‘non
allopaths’- the non-qualified as per the MTP Act for conducting abortions.
1.3 Suggestions for improvement: Suggestions made by the His, regarding the registration
procedure, were based on their own experiences or on those of their colleagues. An open-ended
questionnaire was used for this purpose. (See Table 3).
Table 3: Suggestions for improving MTP registration procedure
________________________ Suggestion________________________
N(%)
1. Registration should come through within a short time span which
31 (27.0)
should be stipulated in the Act explicitly_______________________
2. The registration procedure should be simplified_________________
23 (20.0)
3. Govemment/concemed authority/offices should be responsive to the
8 (7.0)
applications made
4. Access to information should be improved_____________________
5 (4.3)
5. Some flexibility should be exercised while inspecting the physical
8 (7.0)
standards___________
6. Authority to sanction MTP registration should be decentralised_____
13 (11.3)
7. Blood bank requirement is impractical to meet and therefore should
5 (4.3)
be removed_____________________
8. Training module for non-allopaths should be designed to enable
7(6.1)
them to practice MTP
___________
9. Quality MTP training module should be made available and
3 (2.6)
accessible to those who desire to learn MTP technique____________
10. The level of stipulated qualifications/experience either of providers
14 (12.2)
or assistant providers or nurses should be brought down
11. The qualified medical practitioners should not be asked to seek MTP
10 (8.7)
registration separately_____
12. Others
_________________________________________________ 14(12,2)
Note: These data are elicited from responses to an open ended question. A respondent has offered more
than one suggestions. Responses, therefore, do not add up to 115, the total number of heads of the
institutions. However, the percentages are calculated with N=115.
1.3.1 The registration procedure2: The suggestions were not so much to overhaul the
registration procedure. Instead, the concern seemed to be more about poor implementation of the
MTP Act on part of bureaucrats and the concerned offices. In the table above, the suggestions
from (1) to (6) are mainly about improving the ‘how’ of the registration procedure. Major
concern behind the suggestions seems to be the urge to enhance substantially the operational
effectiveness. His feel that once made, the application should either be passed or rejected as
quickly as possible. In case of rejection, the applicant should be given an explanation. His
perceived that this situation could be improved by ‘decentralization of the sanctioning authority’.
2 Medical Termination of Pregnancy Rules, 1975, Section 4 (Annexure 2.9)
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The delay in sanctioning MTP centres was attributed to the centralized sanctioning system at
MTP cell, DHS, Mumbai.
1. "The (registration) procedure is lengthy. Too many documents are required. Criteria to be
met are very stringent. Government should take initiative and sanction MTP centres in
proportion ofpopulation. (Government) should provide the centres with required resources and
should disseminate the required information. ”
2. "... We have to struggle hardfor these things (registration). (It) should not take so much time.
How could we find time to visit (the concerned offices) so frequently? ”
3. “... Here there is a big Civil Hospital (government hospital). An authority to sanction should
be given to them. Andfor that matter even to PHCs. They know everything. DDHS also should
be authorised. An hospital can't be run without basic facilities. The entire bureaucratic
procedure, therefore, should be simplified".
4. "... Red tapeism (bureaucratic functioning) should be stopped... Upon receipt of an
application, lyes' or do’ should immediately be communicated to (the applicant) after an
(required/prescribed inspection. Doctors don't want to run the risk because of CPA3 If so, the
needy don't have access to (abortion) services. ”
1.3.2 Physical standards4, and qualifications of doctors5 and nurses: Suggestions (8) to (12),
(41.8% of the total), in Table 3 fall in this category. Fourteen respondents felt that the stipulated
qualifications for providers and/or assistant providers and/or nurses were over-prescribed. Three
mentioned the inadequacies in the MTP training facilities. Seven explicitly mentioned the need
of designing the MTP training module. This, according to them, would allow non-allopaths to
practice MTP within the legal framework. As one would have anticipated, such responses came
from non-allopaths. As against this, the suggestion that the ‘qualified (gynaecologists) should
not be expected to seek MTP registration separately’ came mostly from the gynaecologists.
Some of them explicitly mentioned that the non-qualified should not be given MTP registration.
Though these conflicting views, and, the attitude of medical fraternity to safeguard their own
interests are not revealingly new, they certainly raise a wider issue of whether to allow non
allopaths to practice MTP. The issue is complex because it has direct implications for women’s
access to safe and legal abortion and also because a large number of non-allopaths are involved
in abortion care. Empirical data from our survey as well as other similar surveys indicate that the
qualified providers and/or MTP registration status of the institution do not necessarily ensure
‘access to safe abortion care’. If so, the issue of involvement of the non-allopaths or even those
allopaths not trained in MTP procedures calls for a wider debate.
The suggestion that ‘the expected level of qualifications of providers/assistant providers/nurses
should be brought down’ was elaborated upon on two points. Firstly, unavailability of such
skilled staff, especially the assistant doctors and trained/degree holder nurses in rural as well as
3 The Consumer Protection Act
4 Medical Termination of Pregnancy Rules, 1975, Section 4, sub-section l(ii) (Annexure 2.9)
5 Medical Tennination of Pregnancy Rules, 1975, Section 3 (Annexure 2.9)
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114
in urban areas and in private as well as in public health care institutions was argued. Secondly,
it was felt that such trained assistance was not required for MTP procedure. The providers
expressed the same views on this issue. They will be discussed elsewhere in this chapter.
1.4 Compliance with the MTP Act: By and large His were found to be either ignorant or illinformed about the following two post-registration legal requirements:
1.4.1 Informing the concerned office about the change in MTP provider: Only 6 of the 39
heads of the registered institutions (HRIs) knew that it was necessary to inform the concerned
office when MTP provider was changed. Except one, the rest five were aware of the underlying
legal rationale: the minimum qualification for the provider laid down by the MTP Act. Four of
the HRIs did not know about it. Thirteen said that they did not or would not inform such a
change to the concerned offices. The explanations offered by them were, ‘since the providers are
trained/qualified, they did not/would not feel the need to inform’, ‘the Act did not mention so’,
‘such a communication was required in case the head of the institution changed’.
1.4.2 Reporting of the MTP cases and the periodicity of reporting6: As per the MTP Act,
registered centres are expected to send a weekly statement of MTP cases to the Chief Medical
Officer of the State. The majority (32 of 43) of HRIs stated that they had been reporting MTP
cases. The reporting offices mentioned include Civil Hospitals, Zilla Parishad, DHS-Mumbai,
DDHs, Circle, and. Primary Health Care Centre. Except one, the rest said that they reported
every month. However, the information that we have from the respective offices does not match
with these data, both in terms of number of institutions claimed to have reported and the number
of the MTP cases. It seems that though they were aware of the legal requirement of reporting,
they were ill-informed about its periodicity and the reporting office.
Whether heads of institutions are complying with the legal requirement of reporting, is an
important question. Weekly reporting of MTP cases to the concerned offices is impracticak
Besides, validity of such data in absence of a monitoring mechanism is also questionable. Such
unsystematically recorded data are of little use. Thus, firstly, there is a need to activate the
monitoring mechanism to ensure validity of the data. Secondly, the periodicity of reporting also
needs to be changed.
At the end of this section we can say that in general, heads of the institution were found to be
poorly informed or ill informed about various aspects of the Act. A wide range of
misconceptions prevailed among them, especially regarding the legal specifications of physical
standards. This appears to have affected the extent of their efforts towards seeking an MTP
registration. Once registered, the compliance on their part with legal specifications was rather
poor. This reflects their ignorance as well as apathy towards meeting the legal requirements.
The data clearly makes a case for systematic dissemination of information amongst
prospective applicants about the MTP Act and the process of registration.
6 Medical Termination of Pregnancy Regulations, 1975, Section 4, sub-section 5 (Annexure 2.9)
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115
2. CONTENT OF THE MTP ACT
2.1 Physical standards: As stated earlier, heads of the institutions were asked to opine on
appropriateness of the stipulated physical standards at the institution. An overwhelming
agreement (111 of the total 115 respondents) with the stipulated standards indicates that medical
fraternity accepts them as essential. Only 4 of 115 His felt that the stipulated standards laid
down in the MTP Act were more than required. According to them, the instruments for
abdominal surgery were unnecessary for the MTP procedure.
Against this backdrop, as discussed in the chapter on physical standards, it is disappointing that
in reality the physical standards at their institutions> were nowhere close to those stipulated in the
MTP Act.
2.2 Qualification of abortion providers: The minimum qualifications laid down for an MTP
provider are part of the Central Act. The MTP Act states that a medical doctor is eligible to
provide abortion services if he meets one of the three conditions. Abortion providers were
asked to opine on appropriateness of qualification stipulated for them. According to the MTP
Act, the MTP provider must have one of the three qualifications (Annex 2.9). Their responses
about appropriateness of these three qualifications vary to a great extent (See Table 4). It,
therefore, suggests that these three conditions are not comparable according to the providers.
This is discussed later in the chapter.
Table 4: Whether the stipulated qualifications in the MTP Act are
overprescribed, appropriate or underprescribed?
____________ Qualification___________
For MTP providers_________________
1. Six months of surgery in gynaecology
Overprescribed
15 (12.9)
Appropriate
Underprescribed
69 (59.5)
32 (27.6)
Total
116
(100.0)
2. Experience at any hospital for not less
than a year in practice of OBGY_____
3. Experience of assisting a registered
practitioner in performance of 25 MTP
cases in an established hospital______
For Assisting doctors________________
Certificate indicating experience as
assistant doctor during abortion procedure
and for minimum 2 years at the institution
For Nurses_______________________
Qualification certificate, registration with
the Maharashtra Nursing Medical Council,
and certificate indicating experience as
assistant nurse during abortion procedure
at the government recognised institution
15 (12.9)
77 (66.4)
24 (20.7)
2(1.7)
52 (44.8)
62 (53.4)
87 (75.0)
26 (22.4)
3 (2.6)
116
(100.0)
116
(100.0)
116
(100.0)
50 (43.1)
66 (56.9)
116
(100.0)
In general, opinions about appropriateness of the first two conditions were less divided.
However, they were clearly divided in case of third condition.
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116
In general, providers who felt that the conditions were 'over-prescribed', were concerned with
their practical possibility, while those who found the conditions 'under-prescribed' were
concerned with the quality of training, experience, and, the grasp of the trainee. The providers
who said that either of these conditions was ‘over-prescribed’ felt that it was not practical to
expect availability of trained doctors anytime & everywhere. Those who said that either of these
conditions was ‘under-prescribed’ explained that the duration of experience was not very
important. Instead, providers’ experience gain in terms of hands-on practice covering wide
ranging cases and probable complications was important. Some mentioned that the providers
should be able to judge the position of uterus and should be confident about it. Many
emphasized that assisting MTP procedures was of limited use as far as gaining expertise was
concerned. Instead, conducting the procedures on one’s own responsibility was very crucial to
feel confident about it. Before switching from ‘assisting' to ‘doing independently’, one should
perform the MTP procedure under the ‘supervision of trainers’ as an intermediate stage. Some
mentioned that MTPs should be conducted only by gynaecologists. The various other concerns
expressed were ‘the type of hospital where the trainees are placed’, ‘the quality of training’,
‘expertise of the supervisor’ and ‘grasping level of a trainee’.
Table 5 cross-tabulates opinions of providers about the stipulated qualifications of doctors
against their own qualifications.
Table 5. Whether the stipulated qualifications are over-prescribed, appropriate or under
prescribed?
Experience of assisting a
Experience at any hospital in
registered medical practitioner
the practice of obstetrics and
in 25 MTP cases at govt.
gynaecology for a period of not
approved centre_____
______ less than a year______
Apr.
U.P.
Total
Apr.
U.P.
Total O. P.
Apr.
U.P.
Total O. P.
Q. P.
17
33
50
37
11
50
2
2
32
16
50
Gynaecologists
(34,0) (66.0)
(100.0)
(MDs+ DGOs)
(4.0) (74.0) (22.0) (100.0)
(4.0) (64,0) (32.0) (100.0)
7
4
11
2
7
2
11
2
9
11
Allopaths with
(36.4) (63.6)
(100.0)
18,2 (100.0) (18.2) (63.6) (18.2) (100.0)
(81.8)
MTP training
10
23
13
5
23
6
12
6
9
8
23
Non-gynaec
(56.5) (43.5)
(100.0)
allopaths____
(26.1) (39,1) (34,8) (100.0) (26,1) (52.2) (21.7) (100.0)
2
18
12
32
21
6
32
5
7
19
6
32
Non-allopaths
(100.0)
(21.9) (59.4) (18-8) (100.0) (15.6) (65.6) (18.8) (100.0) (6-3) (56.3) (37.5)
116
62
24
116
2
52
77
116
15
15
69
32
Total
(100.0)
(59.5) (27.6) (100.0) (12.9) (66.4) (20.7) (100.0) (1.7) (44.8) (53.4)
__________ (12.9)__________________
O. P. = Over-prescribed, Apr. = Appropriate, U. P. = Under-prescribed.
Qualification
of the
respondent
providers
Six months housesurgency in
gynaecology & obstetrics
As regards first two conditions there was not much difference across ‘qualification of respondent
providers’. However, as regards the third condition, non-allopaths, and allopaths other than
gynaecologists exhibited a reverse trend than that of gynaecologists, and allopaths with MTP
training. More than fifty per cent of non-allopaths and non-gynaec allopaths said that the third
condition was appropriate whereas only about little more than one third of the gynaecologists,
and the allopaths with MTP training (34.0 % & 36.4% respectively) agreed that it was
appropriate.
Doctors' opinions about availability of trained doctors hold true to a great extent. Does this mean
that women should be exposed to unsafe abortion care in the absence of trained doctors? Or
Ch- m
117
The MTP Act: knowledge and perceptions of
the heads of institutions and the providers
should we address the issue by taking some measure to improve the situation? Doctors' emphasis
on the importance of hands-on training is also rational. The question is how could this concern
be translated into a reality? Rationality of these responses get rather tainted when we observe
that qualifications of respondent doctors are affecting their responses (See Table 5). It actually
alerts us about the vested interests of doctors of various systems of medicines who are engaged
in abortion care. We will take this argument ahead in the discussion towards the end of the
chapter.
2.3 Comparability of qualifications of provider as stipulated in the MTP Act: We, earlier
had made reference to the fact that opinions of the providers about appropriateness of
qualifications (medical education and/or training experience vis-a-vis the MTP Act) of doctors
as stipulated in the MTP Act did not follow quite the same pattern. This, we considered as a
pointer to providers’ perception/ understanding that these were not comparable. Providers did
not feel that fulfilling one of these stipulated conditions would fetch equal level of expertise (See
fables 6 & 7). If this is the case, this needs to be debated between medical fraternity on one
hand, and policy makers on the other.
Table 6: Comparison among stipulated qualifications of the
abortion providers: Providers’ perceptions
Opinions of providers
Number & %
All ca\ ‘b’ & Cc’ are appropriate
36(31.0)
Only ‘a’ and ‘b? are appropriate_____________
26 (22.4)
Only (‘a’ and ‘b’) or (‘a’ and Cc’ ) are
6(5.1)
appropriate___________
___________
All ca\ ‘b? and ‘c’ are underprescribed_______
20(17.2)
Others
28 (24,1)
N = 116
a: Six months of surgency in gynaecology & obstetrics
b: Experience at any hospital for not less than a year in practice of OBGY
c: Experience of assistance to a registered practitioner in performing 25 MTP
cases in an government approved hospital for such practice
Table 7: Opinions about comparison by respondent providers among stipulated
qualifications of providers by qualification of respondent providers
Qualification of
respondent providers
Gynaecologists (MDs +
DGOs)_______________
Allopaths with MTP tmg
All
‘a’ & ‘b’
‘a’ & ‘c’ or
All
Others*
Appropriate appropriate ‘b’ & ‘c’
Under_______
appropriate prescribed
15 (30.0)
15 (30.0)
2 (4.0)
10(20.0)
8 (16.0)
3 (27.3)
4 (36.4)
1(9.1)
2(18.2)
1(9.1)
Non-gynaec allopaths
6(26.1)
2 (8.7)
1 (4.4)
4 (17.4)
10(43.5)
Non-allopaths
12 (37.5)
5 (15.6)
2 (6.3)
4(12.5)
9(28.1)
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The MTP Act: knowledge and perceptions of
the heads of institutions and the providers
Total
50
(100.0)
11
(100.0)
23
(100.0)
32
(100.0)
118
Total
36 (31.0)
26 (22.4)
6 (5.2)
20 (17.2) 28 (24.1)
116
______________________________________________________ (100.0)
* 'Others’ constituted various other combinations and clubbed together as they were not of significance to the issue at hand.
2.4 Minimum qualifications for the assistant doctors: Abortion providers were asked to opine
on appropriateness of minimum qualification stipulated for assistant providers. Three quarters of
the providers stated that the stipulated qualifications were ‘more than required’ (See Table 8).
Table 8: Opinions about appropriateness of stipulated qualifications of assistant doctors
by qualification of respondent providers
Qualification of the respondent
__________ providers_________
Gynaecologists (MDs+DGOs)
Allopaths + MTP tmg_________
Non-gynaec allopaths__________
Non-allopaths
____________
Total
Over
prescribed
40 (80.0)
8 (72.7)
18(78.3)
21 (65.6)
87 (75.0)
Appropriate
Under
prescribed
9(18.0)
2(18.2)
5(21.7)
10(31,3)
26 (22.4)
1 (2.0)
1(9-1)
1(3.1)
3 (2.6)
Total
50(100,0)
11 (100.0)
23 (100,8)
32(100,6)
116
(100.0)
Most of the providers felt that such an assistant is not required. Some of them informed that such
an assistant was not available. Some of the opinions stated by the providers are:
7. “Assistant doctor is not required. He does not do the actual procedure. It is a very minor
procedure. Assistance is not needed.
2. “(Why is) an assistant doctor required? Not even a sister (nurse) is required. I conduct even
tubectomy (procedure) on my own. I have trained myself. Assistance is not required even for
suction as I do it with (suction machines with) foot pump. ”
Providers also aired their frustrations with the existing MTP training facilities:
3. “The one who actually performs the surgery has the job to do. The other one (is) there only to
assist. With such great difficulty that we underwent training. Where the assistant (providers) will
have opportunities for such training? Sassoon (the state run hospital in Pune) has closed down
such a training. ”
Those 22.4 per cent providers who felt that the stipulated minimum qualifications were
appropriate, offered various explanations. A few felt that this was how an experience could be
gained. The other explanations were: ‘if the MTP provider is a medical doctor with only MTP
training, such an assistance is essential’, ‘it was better to have such an assistance in case of
complications’, ‘it is preferable if there are a number of MTP cases to be attended to at a time’,
‘in case of second trimester MTP cases’.
4. “(Qualified) assistant doctor is essential. In case an artery ruptures, assistance of skilled
hands proves to be ofgreat help. n
Opinions do not vary across ‘qualification of respondent providers’. That is to say majority of
the providers regardless of their own qualification, felt that the stipulated qualifications for the
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119
assistant provider were ‘more than required’. However, percentages did show variation. In that,
about 80 per cent of the gynaecologists treated these qualification as over-prescription and
comparatively less number of non-allopaths felt the same way. It perhaps is a pointer to the fact
that, generally, non-allopaths rather than gynaecologists would prefer to have an assistant
provider (See Table 8).
The fact that there is no consensus among the respondent providers about the requirement of an
assistant provider, indicates that the issue needs to be discussed. It generally hints at bringing
some appropriate amendments in the concerned state level ‘Rules and Regulations’. The
discussion among the medical professionals and the other stakeholders (bureaucrats, women
activists etc.) would help attending to this need. Therefore, the perceived ‘over-prescribed’
and/or
‘unnecessary’ legal requirements must certainly be obstructing registration of
institutions.
2.5 Minimum qualifications for assistant nurses: Abortion providers were asked to opine on
the appropriateness of stipulated qualification for the assistant nurses. There appeared a clear
divide among the providers on this issue. A little more than half of them felt that assistance of
such a qualified nurse was ‘more than required’ and the rest felt that it was appropriate. No one
felt that this was ‘under-prescribed’ (See Table 9).
Table 9: Opinions about appropriateness of stipulated qualifications of
assistant nurses by characteristics of providers
Characteristics of
Over prescribed
________ providers
Qualification of the respondent Providers
Gynaecologists (MDs
19 (38.0)
+DGOs)__________
Allopaths + MTP tmg
2(18.2)
Non-gynaec allopaths
11 (47.8)
Non-allopaths______
18 (56.3)
Total___________ _
50 (43,1)
Public/privatebased_
Public___________ _
4 (22.2)
Private__________ _
46 (46.9)
Total
50 (43,1)
Appropriate
Total
31 (62.0)
50(100.0)
9(81,8)
12(52,2)
14(43,8)
11 (100,0)
23 (100,0)
32 (100,0)
116 (100.0)
66 (56.9)
14 (77.8)
52 (53,1)
66 (56.9)
18 (100,0)
98 (100,0)
116(100,0)
The explanations offered for 'over-prescribed' show that nursing assistance is not required for
abortion procedure (See Table 10).
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120
Table 10: Whether the stipulated qualification of Assistant nurse is appropriate?
Over-prescribed, because
1. In-house tmg/experience of
assisting operative is sufficient
2. Such a trained nursing
assistance is not required
during MTP procedure______
3. No explanation offered______
Total
Freq &
Appropriate, because
Freq &
%
%
25 (50.0)
20 (30.2)
1. because such a trained
assistance is required_______
20 (40.0) 2. but practically not possible to
have such a trained assistance
5(10.0) 3. No explanations offered
50 Total
(100,0)
29 (44.0)
17(25,8)
66
(100.0)
Some of them referred to the economics involved in it. Over-prescription was also perceived in
terms of‘impracticability’ of such a demand.
1. “She (nurse) has minimum role to play (in abortion surgery/procedure) and therefore need
not be a registered one.,f
2. “In rural areas, it is rare to get qualified nurses. (Besides,) the provider is responsible (for the
procedure). He does train them (in-house). Hardly, Rs 600/ - (for a MTP procedure) are earned.
Where would trained nurses' heavy salaries be paidfrom? "
Some poured out their agitation and sour feelings for the policy makers, who, according to them,
were far away from understanding the ground realities.
3. “It is not practical! All these Acts are made (/drafted) in Delhi sitting in Air-conditioned
rooms. They don I know what India is!"
Those who said that such a trained assistance was required re-emphasised the same fact while
explaining it (See Table 10). Some suggested ways as to how it could be done:
4. “Number of nursing colleges should be increased. There should be two years ’ course in
Maharashtra. They should undergo an internship of an year in a big hospital. Any hospital
should have at least one such (qualified) nurse. Hospitals should not be recognised, otherwise
(without such a qualified nurse). ”
However, a large number of them also expressed a view that though such a trained assistance
was appropriate, it was close to impossible (See Table 10).
5. “Trained nurses should be there. (However), such trained nurses are not available in rural
areas even after paying luxuriously (fat salaries). They don 4 like to be here at small places,
(instead) prefer to be in big cities like Pune and Bombay".
The data on ‘human power’ at these health care institutions have been discussed in the earlier
chapters. The majority of the institutions were found to be equipped only with in-house trained
‘nurses’. This fact does not match with the claim by some providers that such an assistance was
appropriate. This raises wider issues about ‘quality of nursing care’ that health care institutions
offer to users of health care services.
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The data presented in this section indicate that there exist colossal gaps between the prevailing
situations as regards physical standards as well as qualifications of abortion care providers and
the positions taken by the His and providers on those aspects. Thus it appears that the
compliance with the conditions stipulated by the MTP Act on part of the His and the providers
was low. This reflects very clearly on three facts. 1) The MTP Act monitoring mechanisms and
systems are almost non-fiinctional. 2) The medical fraternity is trying to give an impression that
it wants the situation to 'ideal' as far as physical standards are concerned and that it is beyond
their control and they are not responsible if the situation is not ideal. 3) Views as regards
‘unavailability of stipulated expertise’ or ‘impracticability’ have persisted throughout the data in
this section. The disagreement among the respondent providers on the required qualifications
for a MTP provider, itself indicates that the three stipulated qualifications do not fetch the same
level of experience and competence. These views, therefore highlight a need for a review of the
MTP Act afresh.
3. THE MTP TRAINING FACILITIES
3.1 Avenues to learn MTP skills: Providers without formal training in gynaecology (n=66)
were asked where they learned to conduct the MTP procedure (See Table 11).
Table 11: Place of learning and employment status of providers while learning
MTP skills
Place of
learning MTP
skills
Public hospitals
Private health
care institutions
Both
(pvt & public)
Total________
Total
Employment status
Formal*
(Student)
8(25.8)
8 (12.12)
MTP**
training
12 (38.7)
12 (16.7)
Inservice***
11 (35.5)
17(54.8)
Informal****
14(45.2)
31 (100.0)
31 (100.0)
3 (75.0)
1 (25.0)
4(100.0)
31(48.5)
15 (22.7)
66 (100.0)
Of the 116 respondent providers, 50 were gyncacologists who are not expected to undergo MTP training
over and above their formal diploma or postgraduate courses in gynaecology.
♦Formal- during medical education; ** MTP tmg : Through MTP training facilities provided under the
MTP Act; ***In-service: While employed ; ****Informal: own set-up, relatives, friends.
The data indicate that both, public and private health care institutions had almost equally
provided the learning opportunities to providers. However, the formal training, either during
medical education or during the MTP training course, had little role to play. It is interesting to
note that a very small number of providers had acquired their skills during their formal medical
education. A large number of MTP providers had learnt MTP procedures during their service
tenures either at private or at public health care institutions.
A substantial number of providers had picked up MTP skills informally, at private health care
institution, either at their own setups or at institutions of their friends or relatives.
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These data underscore the dire need of setting up MTP training facilities, easily accessible to
those interested doctors. It again reflects on poor monitoring system on part of the concerned
government authorities and the need to improve it.
3.2 Training facilities offered by the Government: Eleven of the 115 providers, had
undergone MTP training. They were asked to opine on (a) infrastructural facilities available for
training, (b) the content of training and (c) the skills of trainer. All of them were satisfied with
the infrastructural facilities at the training hospitals. This is not surprising because they
underwent training at the government teaching medical hospitals. Most of them said that they
were satisfied with training as regards content as well as skills of the trainers. It was either
because of the situations were better there than those of their working ones, or sometimes it was
attributed to ‘experienced and higher education of the trainers’, or because trainee were friends
with the trainers’. A few also mentioned that a lot depended upon how much initiative was
taken by trainee. Two of them were dissatisfied because hands-on practice was not up to their
expectations. It was said that the trainers were not interested in trainees. Trainees were hardly
trusted in, to conduct the MTP procedure.
3.3 The training in counselling: Currently, formal training in none of the systems of medicines
up to bachelor’s level includes training in counselling. MTP training modules too do not find
any place for training in counselling skills. Against this backdrop, providers were asked if they
found such a training necessary. A large number of the providers felt the need for ‘training in
counselling’ to better deal with abortion seeking women (See Table 12 & 13).
Table 12: Should MTP training include training in counselling?
Freq & %
76 (65.5)
40(34.50)
__________ Yes/No
Yes, it should_____
No, not required
N=116
Table 13: Whether training in counselling should be included in the MTP training
modules?
________ Yes, why?_______
1. For the benefits of patients
2. For providers’ benefits
3. For mutual benefits of
patients and providers
4. It is the responsibility of
providers____________
No explanations offered
Total
Freq & % _________ No, why?______
45 (59.2) 1. It is part of the medical
training and practice
20 (26.3) 2. Instead, nurses should be
trained for counselling
5 (6.6) 3. Counselling does not help
Freq & %
29 (72.5)
4(10.0)
7(17.5)
5 (6.6)
1 (1-3)
76(100.0)
Total
40(100.0)
The providers who believed that training was essential, felt that counselling might help
providers: to persuade women in good faith to continue with the pregnancy, to make women
aware of the situation, to deal in a better way with women’s psychological pressures, to elicit
Ch- VII
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123
required information from women smoothly, to convince women about contraception, to have
better dialogue with family members of women etc. Some felt that counselling would reduce the
number of MTPs in future.
About 26% of the providers felt that it would be for their own benefit to have a training in
counselling (See Table 13). They felt that it would help them to develop better understanding of
woman’s situation, to form positive attitude about women’s abortion needs, to generate healthy
dialogue with the women clients in such situation etc.
A large number of those who disapproved of the idea of training in counselling felt that it was
very much apart of their medical training and/or providers did practice such counselling for their
clients (See Table 13). Four of them felt that such a counselling was more a duty of nurses than
that of providers. Seven of them were skeptical about the usefulness of such a counselling to
women.
3.4 Prevailing MTP training facilities: We made an attempt to understand the situation at an
MTP training centre and interviewed a trainer so as to get a comprehensive picture of the current
status of MTP training facilities.
The MTP Act does not detail any of the aspects of the MTP training. We had to interact with
concerned office holders7, in order to find out about the process involved in the enrollment for
training..We tried to get information about eligibility conditions for training, the application
process, the process of screening of applications, the finance for the training, the institutions
authorized for training and the structure of training modules.
3.4.1 Who can apply for the MTP training? We could get relevant information only after
interviewing several office bearers. Applications are processed by the Additional Director,
Health Services. This responsibility has been transferred from the Directorate of Health
Services, Mumbai (State level) to the regional offices. Applications of doctors working in the
public health sector with MBBS degree alone are processed through this office. There is no
specific application form, per se. A doctor either puts up a request for training himself/herself or
his/her superior recommends a candidate for such a training. Either way the application as a part
of the procedure has to be forwarded by the superior of the applicant. One of the sources told us
that it has been the policy of the government to train as many doctors as possible who are posted
at PHCs.
However, according to the information received from those at the government recognised
training institution, names of trainees are sent to the concerned training centers (teaching
medical hospitals) by Directorate of Health Services (DHS). These may include those serving in
public health care sector as well as those who have their private practice. They were not aware
of the details of the process and the channel, though. The training institutions do not have any
authority to admit trainees for MTP training on their own. But, they seemed to have a say in
deciding as to how many trainees from the recommended ones could be admitted at their
institution. Information from various sources did match on this aspect.
7 These include, a bureaucrat at the DDES, Pune; the Office of Additional Director of Health Services situated at
the State Dept of Family Welfare; and an office holder and trainer at the medical teaching hospital.
Ch- VII
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124
One of the sources told us that there were no trainees recommended since 1995.
The trainees have degrees like MBBS, MS or even MD (gynaecology). The trainer opined that
a degree in gynaecology did not necessarily ensure required skills. It depends, according to him,
on the quality of medical education that s/he had undergone.
3.4.2 Financial support: The number of recommended trainees is determined by availability of
funds in the given budget. The training institutions then are provided with contingency to
support these trainees. However, as mentioned above, it remains a prerogative of the training
institutions as to how many of them to be accommodated at a time.
3.4.3 MTP training centres: Hypothetically speaking, all the Civil Hospitals and Rural
Hospitals are authorized to offer MTP training. However, our field experience indicates that it is
not a practice. There were no trainees at either Rural Hospitals or at Civil Hospitals that we had
visited. Earlier some of the Corporation Hospitals used to provide MTP training. At the moment
only the state run hospital (teaching hospital) and other two hospitals which are partially
supported by the government have recognition for MTP training
Most of the information that we obtained about the actual training refers to medical college
hospitals. In these hospitals the trainees are accommodated in the regular practical courses that
are conducted for postgraduate medical students. Only about two trainees can be accommodated
at a time. The training is not conducted round the year. The trainer elaborated upon the
constraints in accommodating more than two trainees at a time. Postgraduate students are given
priority over the trainees. Hence, if sufficient MTP cases are not available, trainees are left with
less scope to get hands-on practice of the procedure. The trainer also expressed his resentment
about spending time for these trainees -
1. 'In any case, they (trainees) don’t necessarily use these skills at PHCs (or at the government
set-ups yvhere they are employed). They perform MTPs at their private clinics
Bureaucrats too, expressed resentment about training doctors who are in the government service.
According to them -
"The employees won’t disclose about their MTP training. Some don’t because they are not
interested in offering MTP services. Some others won’t disclose that they perform MTPs
because it means that they have to report (to the concerned authorities). If so, they can’t charge
(their clients). ”
The bureaucrats were aware of the fact that MTP services are being offered at PHCs up to any
length of gestation, at a price, regardless of whether the set-up meets minimum physical
standards and other legal requirements.
3.4.4 Syllabus for the MTP Training: There are no specific guidelines, leave alone the
syllabus, either for theoretical or practical training. The trainer said that no theory was taught
during such training. However, the certificates were issued only after the trainers were satisfied
with the skills acquired by trainees. He emphasised the importance of acquiring the ability to
judge exact length of gestation. This, according to him, requires an experience of about 200 per
vaginal examinations (PVs).
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125
The trainer highlighted that (a) the trainees are given equal opportunities as those given to the
postgraduate students for hands-on practice, (b) the trainees observe the trainer performing the
procedure. In that, the ‘feel’ of the uterus at various stages is demonstrated, (c) all the abortion
procedures are not taught, (d) they are allowed to conduct MTPs independently only after
trainers feel confident about trainees' skills.
He emphasised that trainees need not have an expertise to deal with complications. It was
sufficient to be able to recognise indications of complications at appropriate time so that the case
could be referred.
In sum, the concerned offices should critically look at inadequate MTP training facilities.
Improvements are required at various levels. These include streamlining the procedure,
disseminating information about this procedure to the medical fraternity as well as the concerned
bureaucrats, increasing the MTP training budget, inviting a discussion so as to recognize some
of the private health care institutions as MTP training institutions. The data also indicate that
there is need to improve the monitoring of registered institutions.
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126
4. THE LEGAL REQUIREMENT OF BLOOD BANK :
HOW SCIENTIFIC AND FEASIBLE?
The State level ‘Rules and Regulations, MTP Act' stipulates that a health care centre providing
MTPs up to 20 weeks of gestation must have a blood bank at a distance less than 5 km. The
applicant is required to produce a guarantee/assurance letter from the proprietor of the blood
bank.
We earlier have seen that the majority of the ACFs in the study area did not have access to blood
bank as stipulated in the legislation. Below is a brief situation analysis of the availability of
blood banks in the selected districts followed by an analysis of the blood requirement during
abortion care.
4.1 Availability of blood banks in the study area: Currently a total of 19 public and private
blood banks provide services in the Pune district8. Out of the total of 19 blood banks, 11 are
situated in the heart of the city. These blood banks do not fall within 5 km of some of the
peripheral areas of city itself, leave aside the hospitals at the taluka places. Six of them provide
blood exclusively to the hospitals they are located in. The remaining five provide blood against
any demand from outside. Five blood banks are operating in the periphery of Pune city. There
are only three blood banks in the district which cater to people residing outside the city. They
are: one each in the towns of Talegaon and Lonavala, and one at a taluka place, i.e. Baramati.
The Ratnagiri district has only one blood bank run by the district civil hospital, in the Ratangiri
city. Hence, hospitals outside this city are not eligible to provide MTP services for pregnancies
between 13-20 weeks. However, the data collected during our field study suggests otherwise.
At present, none of the taluka places in Maharashtra, has a government-run blood bank.
At this juncture, as regards the issue of access to blood bank, two questions of immediate
importance are (a) What is the frequency of blood requirements during MTP procedures? Is it
more in second trimester than the first trimester MTPs? (b) Are there any feasible alternatives to
the blood bank, in case of emergencies? We will discuss these issues here.
4.2 The need for blood transfusion during MTP: Gynaecologists say that second trimester
MTPs can be managed without an access to blood banks. They say that blood requirement is not
so much for the induced abortions but for either the post-operative complications or in cases of
spontaneous abortion. In case of the latter, sometimes, the degree of blood loss is tremendous by
the time the woman reaches an appropriate health care centre. It is argued that in such cases the
surgery/operative can be postponed if the haemoglobin level is too low. However, in the case of
induced abortion care, postponing the operative till the Hb status improves may not suit the
women as they have different considerations and prefer to return home the same day.
*
Data on blood requirement: Despite our hard and persistent efforts to acquire hard data on blood
requirement during abortion care, we managed to get only a few general figures. With some
exceptions, heads of the institutions and/or providers were not willing to share the relevant
8 Dr. Ward, Director, Janakalyan Blood Bank, Pune who is also the Chairperson, Pune Chapter, Blood Bank Association of
Maharashtra State (on July, ‘99)
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127
records with us. Sassoon Hospital, a state run hospital in Pune city records two cases of blood
transfusion for the year 1998 of the total 360 abortion cases which mainly included second
trimester abortion procedures. Other private abortion centre (Dr. Bhavsar) in the city which
provides only abortion care records no single case of blood transfusion in his entire career. Dr.
Sanjay Gupte, a leading gynaecologist based in Pune city told us that in last 5 years, there was
not a single case of blood trasnfusion at. his hospital. FPAI, Pune told us that there were no
cases of blood requirement.
To be able to handle the emergencies during MTP requiring blood transfusion is part of quality
care. In this light there is a need to consider the well thought out alternative of unbanked
directed blood transfusion (UDBT) proposed by some experts.
5. SUMMARY AND CONCLUSIONS
■
In general, the heads of the institutions, the abortion providers and the concerned
government officials were poorly informed about the MTP Act. Most of the His and APs
who were comparatively better informed ^do not comply with the legal requirements. This
reflects apathy on part of the medical fraternity to comply and ^oor implementation bn part
of the government authority.
■
The .need for simplifying the MTP registration procedure has come out sharply.
Operational efficiency was demanded for.
■
The stipulated physical standards in the MTP Act seem to be a rather less controversial
issue as overwhelming number of respondents felt that they were appropriate. However, the
reality vis-a-vis physical standards is distressing.
□
As regards stipulated minimum qualification for doctors, non-comparability among the
three alternatives stipulated in the MTP Act comes out sharply.
■
The MTP training facilities are inadequate and inaccessible, especially to those from the
private health care service sector. Given the fact that a Targe number of unqualified
providers are engaged in abortion care service provision it is necessary to consider
improving or almost revamping MTP training facilities.
•
Providers opined against the need to have a qualified assistant doctor and a nurse as a
mandatory ones for MTP service provision. It was articulated that they are not feasible.
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128
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4
Rec
No
Govt(PHC/C
HC/RH/
or Private
Name of the
institution,
address,
landmark
Name of the Head
of the institution
Qualification of
Head of the
institution
Type of Health care
services you provide
(General/
Maternity/
Daycare/ Clinic
Do you provide
abortion care?
(Yes/No)
Do you provide |
D&C care?
(Yes/No)
c
Do you
yourself
provide
abortion care?
(Yes/No)
1
(..cont
d)
Rec No
Are there
additional
abortion
providers?
(Yes/No). It'
yes, how
many?
If yes, name and
qualification of
Abortion
Provider (AP)- 1
Name and
qualification of
Abortion
Provider (AP)- 2
Name and
qualification of
Abortion
Provider (AP)- 3
Name and
qualification of
Abortion
Provider (AP)- 4
Registration
status of the
institution
(Registered/no
n-registered)
(Observation) !
Is the MTP
certificate
displayed?
(Yes/No)
(Observation)
Is the
Abortion
Board
displayed9
(Yes/No)
i
l
F
i
J 11
Phase
-S u -s v e 7
2-6
Annexure
INTERVIEW SCHEDULE TO BE ADMINISTERED WTH THE HEAD OF THE
INSTITUTION
1.
2.
3.
Schedule no:
Name of the interviewer:
Date:
Section I: Profile of the institution
4.
5.
Name of institution :
Address and landmark .
Pin code :
Tel:
6.
7.
Institution type :
1. PHS
3. Cottage Hospital
6. Private
2. PHC
4.Corporation/Muncipalty
Structure of the institution :
1. Maternity hospital
4. Anyother specify
..
2. General hospital
8.
Name of the head of the institution :
9.
Sex:
1. Female
10. Age
yrs
3. Only abortion centre
2. Male
11. Qualification (pl. record actual degree):
1 Post graduate
3. PG Certificate
5. Other, pl. specify-----------
12. System of medicine :
3. RH
5. District hospital
1. Allopathic
3. Homeopathic
2. PG Diploma
4.Graduate
2. Ayurvedic
4. Others, pl. specify
13. (In case ofnon-govemment institution) Owership of the institution :
1 Individual ownership
2. Partnership
3. Trust
4. Society
5. Corporate
6. Cooperative
7. Any other, pl specify
14 Total no of beds
If there are separate O/G beds, number -—
If there are separate abortion beds, number
15. What is the proportion of the abortion clients of the total women clients?
IS-HI
1
16. Personnel: (in case ofdoctors pl.
No
Category
1.
Doctors
1.
2.
3.
4
5._________
Anaesthetist
1.
2._________
Laboratory
Technician
2.
3.
4.
Sex
Age
for those performing abortion)
QiiaHricatlons
Including
specialisation
Training
(in case of non-gynaec
ab'jrJlojiprortdeTsj
Attached/on
caD/regular
employee
NA
Social worker
NA
NA
NA
NA
17. What are the job responsibilities of the social worker (if applicable} ?
18. In case of emergencies in abortion what is the back up you have in terms of expertise/ consultants?
Section II: Abortion services
19. Up to what length of gestation do you provide abortion services?
1. upto 12 weeks
2. 13-20 weeks
3. 21 to 24 weeks and above
20. ( if only 1 is selected or only 1 and 2 are selected in the above) Why don’t you provide abortion
services for 113-20 weeks and/or 21 to 24 weeks of gestation length?
1. don’t have equipment
2. don’t have space
3. don’t have skills
4. not remunerative
5. don’t get enough cases
6. no re fen al nearby
7. more nsk involved
8. legally not allowed
9 don’t approve of
10 any other, pl. Specify
21. How much do you charge for an abortion in case of (only when applicable)Duration of pregnancy
Upto 12 weeks
13-20 weeks
21-24 weeks
Cbarge In Rs.
22. How are drugs supplied to the client for abortion?
1. In-house facilities
2. Replacement of essential drugs
What docs It Include?
3. No drugs are supplied
23. Card exercise We have listed five factors which may detennme cost of abortion. Will you please rank
them in descending order that is followed at your centre as determinants of the abortion cost ,
Ranks
1__
2
_____ Sr nos of determinants
3
4
5
IS-HI
2
(Administer this section only ifHI is the person who decides regarding taking up abortion cases)
Section ill: Access to abortion services
24. We have made a list of reasons for which women seek abortion. Please rank them in descending order
with reference to this centre?
Ranks
Sr. nos, of reasoiw
25. Do women come alone to get an abortion done?
1. Yes, under what situations?
2. No
26. Do / will you provide her abortion services if a woman comes alone?
l.Yes
2. No, why?
27. Do/will you conduct abortion if woman’s ftiend/s accompany her?
l.Yes
2. No
28. Do you provide abortions services to singles, such as, unmarried widows, deserted/separated?
l.Yes
2. No, why?
29. Do you provide abortion service to a married primie?
l.Yes, why?
2. No
30. Do you make it compulsory for a woman to accept lUCD/sterilisation after abortion?
l.Yes, why?
2. No
31. Do/will you provide services to HIV positive women?
1. Yes
2. No, why?
32. (Ifyes) Do/will you charge more for such cases if you provide services to them ?
1 Yes
2. No
9. NA
33. Whose consent do you take before conducting abortion?
1. Only woman herself
2. Only her husband, why?
3. Both, woman and her husband, why?
4. Parents/in-laws/close, responsible and elder relatives, why?
34. (If 1/3/4 to above Q) Do you insist for husband’s signature?
1. Yes, why?
2. No, why?
IS-HJ
3
35. Do you take second opinion for abortions between 13-20 weeks?
1 Yes
2. No
9. NA
36. The MTP Act provides abortion in case of:
a). Failure of any contraceptive device or method b). Danger to life of the pregnant woman
c). Grave injury to physical health of woman d). Grave injury to mental health of woman
e). Pregnancy caused by rape fl. Substantial risk that if the child was bom, it would suffer from such
mental andphysical abnormalities so as to be seriousely handicapped.
Do you think that the Act thus defined provides abortion to all women, irrespective of their mantal
status ?
1. Yes, how?
2. No, how?
37. (Ifno) Do you think all women should have legal access to abortion?
1. Yes, why?
2. No, why?
38. Do you think the MIT Act has helped women in some concrete way?
1 Yes, how?
2. No, how?
Section IV : MTP Act:
Registration status :
39. Is tiie centre registered under tire MTP Act ? :
1. Yes
2. No
40. (If not registered) did you ever try to get your centre registered?
1. Yes, what happened?
2. No,
why?
41. (If registered) year of first registration : 1.19-
9. NA
42. (If registered) is tlie registration for - 1. Up to 12 weeks
2. 13 to 20 weeks
9. NA
43. (It registered) do you have to renew registration?
1. Yes
9. NA
44. If yes, what is the period for renewal?
2. No
yrs
9. NA
45. When did you renew your registration last? 19-
9. NA
46. (If regkstered) did you encounter any problems wliile getting the centre registered?
1. Yes, what problems?
2. No
9. NA
47. CTo all, registered and non-registered) What are your suggestions for improving die method of
registration?
48. (If registered) In case, the MTP provider at your <
centre changes do/will you inform to the authority?
1.Yes, why?
2. No, .why?
\9
9. NA
IS-HI
4
Opinion about the Act:
49. As per the MTP Act, a registered centre need to have
a .safe and hygienic conditionsfor conducting an abortion,,
b. operation table and instruments for performing abdominal or gynaecological surgery,
c. drugs and parenteralfluidsfor emergency use.
Do you think that these requirement standards are
1. Too high. How?
2. Just appropriate, how?
3. Too low, How?
Maintenance of the records :
50.
Type of records
Do you have?
Yes / No
How long
are they
maintained ?
Operation theatre registre
(OTR)
(If the records are not
shown) What Information
does It contain?
Case sheets
Consent form for any
operative procedure in
general________
Separate admission register
for abortion clients
Woman’s consent form for
abortion
Doctor’s approval form in
case of abortion clients
51 Are the abortion cases enterd in the OT register ?
l.Yes
2. No
52. Are these entries different than the other entries in OT register?
l.Yes, how?
2. No
Reporting of the MTP cases :
53. (onlyfor registered centre)
l.Yes,
To whom?
1. Zilla Parishad
Do you report the MTP cases?
2. Civil hospital
3. Any other, pl. Specify
How frequently ?
1. Monthly 2. Bimonthly 3. Quarterly 4. Six monthly
5. Annually
2. No, why ?
IS-HI 5
3. Not all cases, why?
9. NA
(Administer this section only ifHl is the person who decides regarding taking up abortion cases)
Section V - Perception :
54. Why do you think women have to face the situations of second trimester abortions?
55. Who do you think is responsible for abortion situations that a woman faces? How?
56. What is your opinion about abortion as spacing method ?
57. What is your opinion about abortion after sex determination?
)
58. What is your opinion about abortion as a woman’s right ?
59. (In case ofregistered)CoM we have look at your MTP registration certificate ?
60. Could we have specimen documents of---- ?:
_ _______Type of (he document
l^Congent form for any operative procedure
2. Woman’s consent form for abortion
3. Doctor’s approval form for abortion-~
Qbtafried/not obtafoed/NA
c:\iuuita\i enptchNieadf.qac
is-in
6
+ H Ve
phase 7T
Annexure
j
we 7.
b)
INTERVIEW SCHEDULE FOR PROVIDER
1.
2.
3.
4.
Schedule no :
Name of the interviewer.
Date :
Name of institution:
Section I - Identificatory data :
5.
6.
7.
8.
9.
Name of the provider :
Sex :
1. Female
2. Male
Age :
- yrs
Qualification {pl. record actual degree):
1 Post graduate
2. PG Diploma
3. PG Certificate
4. Graduate
System of medicine:
1. Allopathic
3. Homeopatluc
5. Other, pl. specify
2. Ayurvedic
4. Others, pl. specify
10. How long you have been doing abortion practice?
— yrs
Section II - Abortion services :
11. (Skip in case HI andprovider are the same) Up to what length of gestation do you conduct abortions?
1. upto 12 weeks
2. 13-20 weeks
3. 21 to 24 weeks and above
How many abortions do you conduct at this centre per month
Length of gestation
Upto 12 weeks
Between 13-20 weeks
Between 21-24 weeks
—? (ask 'whichever is applicable)
Cases per month
13. How many viats woman has to make before you conduct abortion--?
• Up to 12 weeks
--------- visits
• Between 13 -20 weeks-------- visits
• Between 21-24 weeks
visits
14. Which are the most important informations you
15. Which procedure do you use for abortion
mentioned)
Length of gestation
Up to 12 weeks
ask woman before taking her up for abortion?
■? (ask when applicable Pl — under the procedure
Procedure used
Why do you prefer this
Particular method?
VA/ DAC D&E InfraExtra*
amniotic amniotic
——r-—-rinduction induction
Between 13-20 weeks
Between 21-24 weeks
J
IS - PRO
1
16. (Ifinduction is used) Do you use check curettage after induction?
1 Yes, Always. Why?
2. No
3. Sometimes, if required In which situations.
17. Which anaesthesia do you mostly use for abortion
9. NA
?
Duration of pregnancy
Upto 12 weeks
13-20 weeks
21-24 weeks
Type of anaesthesia used
18. Whch pathological tests do you conduct before taking up a case for abortion, as a routine?
*'Hb
2 Rh
3. Urine
4. VDRL
5. HIV
6. Any other, pl. specify------19. Wluch examinations do you conduct for an abortion client just before discharge?
20. Do you prescribe any drugs after abortion is conducted ?
1 Yes, which? Why?
2. No
21. Generally, what post-abortion precautions do you ask women to take?
22. What is the percentage of abortion clients who
come for follow up? (Ifnot 100%) Why is it not 100%?
23. Generally, for wluch post-abortion complications have you treated women?
24. What according to you are the reasons for post-abortion complications?
25. (If conducts abortion between 13-20 weeks) Do you conduct abortion during 13th to 15th week?
1. Yes, why?
2. No, why?
26. Do you insert IUCD immediately after abortion?
1. Yes, why?
2. No, why?
27. Do/will you provide services to HIV positive women?
2. No, why?
(Administer only ifprovider decides regarding taking up an abortion case)
Section in : Access to abortion services
“f" w“
28
1
2
_3_
___ 4 _
5
6
7
“k
pi“e
Sr. nos, of reasons
IS - PRO
2
29. Do women come alone to get an abortion done?
1. Yes, under what situations?
2. No
30. Do / will you provide her abortion services if a woman comes alone?
l.Yes
2. No, why?
31. Do/will you conduct abortion if woman’s friend/s accompany her?
l.Yes
2 No
32. Do you provide abortions services to singles, such as, unmarried widows, deserted/separated?
1 • Yes
2. No, why?
33. Do you provide abortion service to a married primie?
l.Yes, why?
2. No
34. Do you make it compulsory for a woman to accept IDCD/sterilisation after abortion?
l.Yes, why?
2. No
35. Whose consent do you take before conducting abortion?
1. Only woman herself
2. Only her husband, why?
3. Both, woman and her husband, why?
4. Parents/in-laws/close, responsible and elder relatives, why?
36. (If 1/3/4 to above Q) Do you insist for husband’s signature?
1. Yes, why?
2. No, why?
37. Do you take second opinion for abortions in case of 13-20 weeks?
l .Yes 2. No
9. NA
38. The MTP Act provides abortion in case of:
a). Failure of any contraceptive device or method
ethod b).
b). Danger
Danger to
to life
life of
ofthe
the pregnant
pregnant woman
woman
cf Grave injury to physical health ofwoman d). Grave injury to mental health ofwoman
ej. Pregnancy caused by rape/). Substantial risk that if the child was bom, it would suffer from such
mental andphysical abnormalities so as to be seriousely handicapped.
Do you think that the Act thus defined provides abortion to all women, irrespective of their marital
status ?
1. Yes, how?
2. No, how?
IS - PRO
3
39. (Ifno) Do you think all women should have legal access to abortion?
1. Yes, why?
2. No, why?
40. Do you think the MTP Act has helped women in some concrete way?
1. Yes, how?
2. No, how?
Section IV - MTP Act:
41. As per the MTP Act, an abortion provider needs to meet one of the following training requirements —-—. Do you tlunk they are. ?
Training requirements
Over
prescribed
six months ofsurgery in gynaecology
Under
prescribed
Jnst
appropriate
experience at any hospital (more than
one year) in practice ofOBGY
assistance of25 MTP cases'in a Govt,
approved centre)
42. Do you think the MTP training should include training regarding counselling skills?
1. Yes, why?
2. No, why?
43. (Skip in case of gynaecs.) From where did you learn the technique of abortion?
44.
(If trained at the government recognised setup or at hospitals as per the Act) Were you satisfied
during your training about the following :
____
JTraining in terms of
Satisfied, why?
Not satisfied, why/
Infrastructure at the training centre
• Instruments
________• Equipment___________
Content of training
• Theory
• Hand on training of various
___________ abortion methods
Trainer
• Imparting knowledge
• Imparting skills
45. The act prescribes that the assistant doctor should have
• certificate indicating experience as assistant doctor during abortion procedure and for
minimum 2 years at the institution
Do you think this is —-?
1. over prescribed, how?
2. just appropriate
3. Underprescribed, how?
46. The act prescribes that the assistant nurse should have
• qualification certificate (1/2/3 yrs nursing course)
• registration with the Maharashtra Nursing Medical Council, and
• certificate indicating experience as assistant nurse during abortion procedure at the
govenunent recognised institution
Do you think this is —-?
1. over prescribed, how?
2. just appropriate
3. Underprescribed, how?
IS - PRO
4
Section V - Perception :
47 Why do you think women have to face the situations of second trimester abortions?
48. Who do you think is responsible for abortion situations that a woman faces? How?
49. What is your opinion about abortion as spacing method ?
50 What is your opinion about abortion after sex determination?
51. What is your opinion about abortion as a woman’s right ?
Section VI : Views about abortion practice by non allopaths, paramedical and iocal
abortionists
"
52. What do you chink about non-allopathic medical professionals practicing abortion?
53. Do you think paramedicals such as ANMs, trained birth attendants (TBAs) Nurses dais
could be trained for Menstrual Regulation (MR) for conducting abortion?
1 Yes
2. No, why?
54. Do you think local abortionists could be trained for MR for conducting abortion ?
1 Yes
2. No, why?
tramin8 paran,edlcals and/or local abortionists will affect the practice of the abortion
55
l.Yes
2. No
c:\sunita 'reap\ichf\prov4.qac
IS - PRO
5
Phase II
• (Quaom'+c<mve
Annexure
INFORMATION TO BE GATHERED AT THE CENTRE
Schedule no :
Name of institution:
Name of the observer :
Date:
* 1 (Onlyfor registered centre) Display of MTP board and certificate :
No
L_
2.
Item
if yes and * if no)
(Pl.
Yes/No
BoarcDlispla>jn^availability of MTP facilities
MTP registration certificate displayed
•2. Enquiry counter (Peripheral facilities): - (Pl Zifyes and x ifno)
No.
L_
2.
Item_
Enquirycoiuiter
Person attending enquiry counter
Yes/No
*3. Consulting room (Privacy) : (Pl. Zjf yes and x ifno)
No,
. ■' .
Item
Separate consulting room
Conversation is heard outside the consulting room
More than one patient enters theTonsuTfing room"
2.
3. '
*4 Waiting room and consulting room : (Pl.
yes and * ifno)
Observations about
Ventilation
Light
_.._iYes/No
Waiting room
Consulting room
ZZZ-------- ~
Cleanliness (garbage, smell)
Seepage
~
Sink
Water facility at the sink (running/stored in buckets etc)
Drinking water
Whether overcrowded
*5. Wards and special rooms (Pl. Zif yes and * if no)
’Sr
no
J
2
_3_
4
5
6
7
8
Observations about
at Wards
at Special rooms
Ventilation
Light
~
JglganlinesTfgarbage, smelD
Seepage
Drinking water
Toilets
Bathrooms
Whether overcrowded
IS - QBS
1
*6. Wards and special rooms : (Pl. ^if yes and * if no)
No
1.
2.
3.
________ Item _ ___
Condition of cots
Condition of mattresses
Condition of bedsheets
*7. Sanitary conditions : (Pl.
No.
1
2.
3.
5.
*8.
Cowfortable/Clean (Yes/No)
yes and * if no)
Condition of toilets and bathrooms m
the institution
_
Cleanliness
_______
Airy
Light
Running water
~~
Yes/No
Furniture:
1.
2.
3.
Furniture
Examination tables
Stretchers
Trolley
Total no.
*9. Operation theatre : (Pl. ^if yes and * if no)
Whether operation theatre and labour room are separate -
Observations about
Exhaust fan
Light________
'
Cleanliness (garbage, smell)
Seepage
Sink
____
Water facility (running/stored in bucketTetcT
Drinking water
Toilets
Bathrooms
1 Yes
atOT
2. No
at Labour room
NA
NA
NA
10. Information to be gathered at the operation theatre :
—_QPgI<ATlON THEATRE
- _L Operation table (head low)
2. Oxygen cylinder
3. Breathing hoses
4 Self inflating bags
_ 5. Airways
6. Endotracheal tubes
. Boyle’s apparatus
Total no.
11 Information to be gathered about the contents of the emergency tray: (Pl ^if yes and x if no)
.EMERGENCY TRAY_ J
~
1. Adrenaline
2. Glucose l.V.
~
3. Ringer lactate ’ ”
4. Hydrocortisone iiij ^Elfcoriiii^H DexmSTasone
5. Mephentine inj.
6. Avil inj.
7. Dopamine
8.Soda bicarb?
9. Furosemide
Yes/No
IS - OBS
2
12 Information to be gathered about abortion specific instruments and equipment:
(Pl. ^ifyes and * if no)
ABORTION SPECIFIC EQUIPMENT
_________ _
MTP sets
Required for both first and second trimester:
1 Set of dilators (different sizes)
2. Vulsellum
3. Ovum forceps
4 - long ovum forceps (with narrow top end, transverse
serrations and a rachet in the handle for locking)
5. Curette_______
6. Suction machine (electric/hand/foot pump)
7_ Sim's speculum
8. Suction cannula (ideally its size has to match witliThe"
size of dilators that are used for dialatation)
In addition to above following are the intruments
required for second trimester abortion :
_L Catheter (Folly's / Simple rubber)
2. Currette
3_ Ovum forceps (both curved and straight varieties)
4. Laparotomy equipment____________
5. Laparoscope
^O/™a^O,, t0
Total No
8a^*lere<* about Sterilization equipment (essential facility):
Sterilisation equipment
1. Autoclave
2. Pressure cooker
Yes/No
14 Information to be gathered about access to Blood bank : (Pl -/if yes and * if no)
Access to Blood bank
If yes, mention distance
VesZNo
(km)
15. Information to be obtained about complementary services : (Pl v'if yes and *
Whether there is pathology laboratory -1. Yes
i
/
Hem
If yes, tests performed -
2.
if no)
3. No
Yes/No
Urine test
urine sugar
. albumin
. urine microscopic
. pregnancy
Blood test
blood group (inluding Rh)
Hb percentage (Hb)
blood sugar
IS-OBS
3
16. Information to be obtained about Essential Emergency facililcs : (Pl. v'jf yes and
_No.
1.
2
3.
Items
Ctenerator/batiery set
If yes,
. For operation theatre
. For emergency wards/rooins
. For whole setup
Ambuhince
Fire fighting arrangements
fire extinguisher (mention no. . easily accessible water supply
if no)
Yes/No
)
17 Information to be obtained about Complementary facilities : (Pl Zif yes and * if no)
No
1.
2.
Items
Yes/No
Telephone facility
Food facilities patients
relatives
18. Inlomation to be obtained about Disposal of waste ( Pl ^if yes and * if no)
Aborted foetuses
Used gloves
Syringes
_Needles
Packs & Menstrual Pad
Incinerated/Bumt
Common garbage
Any other (specify)
Main Water supply to the institution :
19. Source of water supply -
1. WeU
2. Tap
20. Covered water storage -
1 Yes
2. No
21. Frequency of cleaning water storage
times per
22. Method used for purifying dnnking water Paramedical and other staff:
23. How many nurses do you have?
24. Ofthese how many have fonnal training and how many are registered?
Type of training
Formal training
. Degree
Diploma
Certificate
In-house training
-------- NumbCT ofnurses______ Registration status
Number of nurses
Registered
Non-registered
25. How many ayahs are working ?
How many ward boys do you have?
c:\suniU \n?ep\schl\obs2.qac
IS-OBS
4
£ x ex Oc t; )
A?i
Q 23. We have listed five factors which may determine cost of abortion. Will you please
rank them in descending order that is followed at your centre as determinants of
the abortion.
Q24. We have made a list of reasons for which
women seek abortion. Pleasejank them in
descending order with refecnce to this centre.
(Q 28 in the Interview schedule for provider)
Health status of
women
Rape or incest
Length of gestation
(even within the
particular trimester)
Failure of
contraception
If the women is unmarried ,
divorced, separated or
widow
Spacing method
Economic status of
Women
Risk to mother’s life
After sex
determination
Procedure used for
Abortion
Pregnancy outside
marriage
Eugenic purposes
Annexure 3 O')
Phase 3; Qualitative Case Studies
INTEGRATED OBSERVATION AND IN TERVIEW GUIDE
1.
2.
3.
4.
5.
6.
Name of the institution :
Name of the HI
District:
Name of the interviewer:
Date/s:
/
Name of the provider:
Tahsil:
Village:
I
Common observations about the centre :
7. Waiting penod:
Average waiting time for the clients
Average time spent with clients by the provider
8. Privacy:
Separate consulting room
Conversation is heard outside the consulting room
People other than provider and client sitting in the consulting room (list people present)
(Note : O - Observation, IInterview. Once observed will not be a§ked to the woman. There are
certain tilings which will be only be observed or only be asked to the woman wlule interviewing her.)
I. General:
(Here it will be cither observed by the researcher about these aspects or the woman will be asked
about it.)
9. {1} Name of the woman :
10. {1}Address:
11. {1} Village:
Taluka:
12. (I) Socio-economic status :
Age :----- yrs
Caste working);
Education:
Occupation :
Marital status:
Age at marriage:
District:
Income (if
13. {1} Husband’s identificatory data : (in case of married woman)
Name:
Age:---- yrs
Education:
Occupation:
Income:
Place ofjob:
14. Family income:
15. {1} Land ownership :
Quantity of land owned : Irrigated :-------- acres
Who cultivates the land :
1. Family members
Rainfed:------ acres.
2. Employed labourers
16. {1} No. of family members :
1
D. Pre-operative interactions : Reproductive history
(Here it will be either observed whether the provider seeks information on various aspects from the woman
or the woman wUl be asked if such information was obtainedfrom her by the provider).
17. {0/1} Fertility history : Total Pregnancies
Abortions(Induced/Natural)
Death(M ale/Fem ale)
Living(Male/Feniale)
18. {0/1}Any reproductive illness :
19. {0/1} Experiences of earlier MTPs, if any (Reason, post-abortive complications such
as bleeding.
fever, pain in abdomen, D&C, continued pregnancy, perforation)*
20. {0/1} Use of contraception : (past, source of information, experiences, future plans of family planning
mention of mandatory contraception in this episode)
n'aj°r
21 ^S^etcTe^MHbJ
healt’
“ BP’
Pre-operative interactions (obtaining information): Abortion related
orZ
PrOvide' ^
on Vanous aspects fram the vomun
or the woman will be asked ifsuch information was obtainedJYom her by the provider).
22. fO/7/Menstrual history (LMP, dysmenorrhoea, menstrual cycles regular/irregular)
23. {0/1} Reason for abortion.
24. {0/1} Decision-making regarding doing aborfr
ion (who all from the family or outside participated in the
decision making process)
25. {0/1} If husband/partner was
asked, by the provider to be there? Why?
convuhionslVucps^Tste’ra“’d,Cah°nS
abOrtlOn
methOd USmg Prosta8“ :
27. {0/1} m case of immediate admission obtaining mformation about the NBM (Nd by monthjstatus.
Pre-operative medical examination
28- s
29. {0/1} General
temperature)
sz:—s
—*
examinations conducted (Observation of nails, eyes and tongue, BP, pulse.
30. {O} Pathology tests (Hb, Rh, HIV)
2
31. {0/1} Any other doctor has examined (in case of second trimester abortion)
(Check doctor’s approval form and second opinion response from quantitative format)
V Pre-operative interactions : Giving information to the client about the procedure
(Here it will he either observed whether the provider gives information to the client on various aspects or the
woman wOl be asked ifsuch information was given to her by the provider).
32. {O} Length of gestation
33. {O} Methods to be used for abortion /MTP ( describing these procedures in a way that woman
understands them, seeking clients’ participation in decision-making)
34. {O} Risks /complications involved (these are procedure specific)
35. {O} Legal requirements, if applicable (if consent is required from any one other than the client, filling
up the forms)
36. {0/1} Consent while undergoing the procedure (Check consent form and related data)
37. {0/1} Instructing about being NBM and its reasons in case she is not admitted on the same day.
38. {O} Time required for the procedure, how many days of in-admission at the centre, whether she can
return on the same day, expenses that she has to incur, removal of ornaments before coming for the
procedure (if she is not admitted on the same day) etc.
39. {O} If there is written material for the client about abortion and related issues.
VI Woman's choice of abortion provider : considerations
40. {1} Time taken to reach tire centre :
41. {1} Mode of Transport
42. (1} Date of admission in hospital:
{0/1} Date of procedure :
43. {0/1} Number of visits made including that for the procedure and reasons.
44. {0/1} Companions while visiting the centre (at each visit)
45. /I} Source of information about the provider
46. {1} Considerations while choosing this provider
• competence,
• reputation,
• cost,
• distance.
• facilities,
• time required between the admission and discharge
distance to maintain confidentiality vs cost
any other
3
47. {1} Consulted any other provider/doctor before coming here? Why?
VTL Woman’s evaluation of abortion/MTP care centre :
48. {1} Woman’s evaluation of the the abortion care centre.:
Pnvacy (no. and composition of people inside the cabin, sound prooftiess, privacy during
consultancy, surgery and stay)
• Equipment and pathology/sonography
49. {1} Woman’s satisfaction about other facilities at the centre
• Food facilities
• Ambulance (only if she has required it)
• Water facility
• Telephone facility
' ““ ab°"i0"
<tavel
Desirable cost according to you :
51. {1} Satisfaction about the services of the follwoing and then behaviour will! her
•
•
•
•
•
Doctors, (eg tension about abortion, if doctor assured you)
Nurses,
Aaya,
Wardboy,
Administrative staff
52. {1} Would you give reference of this centre to anyone? Why?
53. il} Card exercise (regarding woman's
evaluation of the centre. Women have to either select or
deselect the cards)
54. {1} Whether MTP 'eave was taken (Record).
Post operative interactions :
55. IO!
•
,f S1,y 1S
befo„ lhc
“to
~
56. {O} Mandatory revisits for check-ups and indications of post-operative complications
• Advised to revisit the provider for routine check'ip after 2 wX
tenZratrX,™ te^pj! fo^moreX. "Ivs “l'1''
U' !°Wer abd°lnen’ nSe °f
more
tlian
7
days.
Persistent pregnancy symptoms
'
Y ’ heavy 01 Persistent fresh bleeding or
• Referrals
57. {O} Post-operative Precautions (Do’s and don’ts )
etc, about gid<fc^“SrS ShrE'aSft Water’ T
blowing and pain will be there imd for Ik>w Ion
c
.... u.1TO)me f„ ,„.,4 4,ys altaab<^n use
f°Od C°llki be iwssible
how much
4
58. {O} Reassurance to the woman and her companions (relatives/fnends) that the procedure was
successful etc.
59. {O} Responds to doubts and querries of the client
IX. Provider - client interactions (Pre-operative):
(For the reference of the peer group and committee only : observations will be made by the researcher
about die quality of provider’s interaction with the client. This particular section will be on the separate sheet.
While documenting, care will be taken that it remains out of site of anyone other than the research team)
60. {O} Provider behaviour towards the client (presence of value loaded statements during
conversation, nasty remarks about client’s sexual life, any comment which directly or
indirectly conveys client that her abortion, need is a result of her/couple’s irresponsible
behaviour)
61. {O} Provider’s responsiveness (does the s/he responds to what client is narrating by raising
more questions or by adding/ complementing/ supplementing to what the client is saying)
62. {O} Provider’s lack of attentiveness (attending to more than one tiling, such as, talking to his
staff attending to other patient, doing something else other than listening to her)
5
c:\sunita\reap\report\annex\ql-metb.doc on Dec 18, ‘99
Annexure
30)
PHASE HI: QUALITATIVE CASE STUDIES
OBSERVATION GLIDE
(interactions between the client, her companions and paramedics, administrative staff, aayas)
Name of the interviewer :
Date/s and time of the session/s :
Name of the institution :
Name of the provider
Tel :
Interactions with the administrative staff, if any :
• Women and her companions are provided with the required information
• Helped her/relatives/friends in completing the paper work at the time of admission and al the
time discharge
• Behaviour pattern
Interactions with paramedics :
• Drugs are given on time
• Supervision of IVs etc
• Preparing the woman for the procedure
• Maintaining the case papers at her bed side
• Reporting to the provider other responsible medico as and when required
• Behaviour patiem
Interaction with aayas and wardboys
• If the woman is provided with care, such as, giving her bed-pans, sanitoiy pads etc as and
when required
• Reporting to the paramedics or to the provider as and when required
• Behaviour pattern
This is only a guideline. However, additional case specific information will be documented.
Annexure 2.5(b)
Phase III: Qualitative case studies
Observation guide
Annexure:
3 CO
PHASE HI: QUALITATIV E CASE STUDIES
INTERVIEW/OBSERVATION GUIDE
FOR WOMAN WITH POST-ABORTIVE COMPLICATIONS
(to study ‘outcome’ component of QAC)
1. Name of the institution :
2. Name of the HI:
3. Name of the provider .
4. District:
Tahsil: -
5. o Name of the interviewer :
6. Date/s :
/
----- Village : —
/
Post-operative complications :
o
7. {0/1} Name of the woman
8. {0/1} What complications
9. {0/1} Length of gestation in that episode.
10. {0/1} Procedure used.
11. {0/1} When was the abortion/MTP conducted?
12. {0/1} Where was it conducted (name of doctor, place)
13. {!) Qualifications of that provider?
14. {1} Registration status of the centre ? .
15. {0/1} Why the same rpovider was not approached?
c:\sunita\reap\report\annex\ql-metc.doc on Dec 18, ‘99
Annexure 2.5(c)
Phase III: qualitative case studies
Interview/observation guide for woman with post-abortive complications
. 1
'I
c:\sunita\reap\report\annex\ql-inetd.doc on Dec 18, *'99
Annexure^.
c«b
RECORD SHEET FOR SCREENING CASE PAPER
(to study ‘outcome’ component of QAC)
1. Name of the institution :
2. Name of the Hl :
3. Name of the provider :
4. District:
--------------5. Name of the interviewer :
6. Date/s :
/
Tahsil :
Village : —-
/
Information to be noted down from the case paper
sr no
Complaints by the
clients as recorded on
the case paper
Date on
the case
paper
(Fever, bleeding, duration
of bleeding, pain in
abdomen)
Diagnosis by the
provider
Treatment
(Perforation,
septicaemia,
haemorrhage,
incomplete abortion)
"t
•
•
Pl. note if spontaneous / incomplete to complete, if any
Pl note D & C, if any
Annexure 2.5(d)
Record sheet jpr screening case papers
1
Annexure - 4
GLOSSARY & NOTES
(For researchers' reference)
Glossary
1.
Abortion : Abortion is the prevention of pregnancy that has already begun from going to term, from
eventuating in childbirth; and abortion may be accomplished through a variety of methods - chemical,
herbal, mechanical, surgical. (R Petchsky. pp 29).
Induced abortion - Willful termination of pregnancy.
Spontaneous abortion - Expulsion from the uterus of the products that is occurring naturally
(Dorland's Medical Dictionary )
2.
Abortion procedures :
-Surgical procedures - Abortion procedure which involves use of surgical tools to clean the
uterus of products of conception.
Medical
■-Meoicai procedures - Abortion procedures where drugs arc used for expulsion of conception
products.
3. Amenorrhoea - Absence or abnormal stoppage of the menses (Dorland's Medical Dictionary)
4. Amniotic sac - Sac of fluid surrounding the foetus. (OBOS)
5. Aspiration - The act of inhaling, removal by suction. (Dorland’s Medical Dictionary )
6. Cervical laceration (Tear) - (Post operative complication - POC) - The cervix may get injured
during a second - trimester abortion. A small tear heals without any treatment. However, a more
serious tear may require stitches, and there may be some bleeding from the tear. (OBOS. pp 359)
7. Clinic - A special place or time at which specialized medical treatment or advice is given to visiting
patients. (Oxford dictionary)
- An establishment where patients arc admitted for study and treatment by a group of phvsicians
practising medicine together. (Dorland’s Medical Dictionaiy)
8. Counselling - Professional advice about a problem (Oxford dictionaiy)
9. Curettage - Scrapping the inside of the uterus with a metal loop, called
a curette, to loosen and
remove tissue. (OBOS)
10. Dysmenorrhoea - Painful menstruation. (Dorland’s Medical Dictionary)
11. Endometriosis - The aberrant occurrence of tissue containing typical endometrial granular and
^l.r0.ma i clcmcnls hi various locations in the pelvic cavity or other areas of the body (Dorland’s
Medical dictionary )
12. Endometritis- Inflammation of the endometrium. (Dorland's Medical Dictionary)
13. Ecbolics
i
that promotes rapid labour by stimulating contractions of the myometrium
(Dorland s Medical Dictionary)
14. Dilation - Enlarging the cervical opening by stretching it with tapered instruments called dilators or
with laminaria. Many medical technicians use the word “dilatation" to mean the same thing. (OBOS)
15. Forceps - Grasping instruments used to remove tissue. (OBOS)
16. Hospital - An institution providing medical treatment and care for ill or injured people (Oxford
dictionary)
K
17. Incinerator : a furnace or enclosed container for burning rubbish (Oxford Dictionary ) It is said that
the gases produced during incineration arc harmful and arc feared to cause cancer amone the
inhalers.
*
18. Infection (POC) - Inspitc of using sterile instruments and antiseptics, bacteria sometimes travel into
fn.dU^rUS rT Of1,nfCClion arc fcver °r 100■5"F or higher, bad cramping, vaginal discharge with
loul odour Tetracycline or ampicillin is the treatment for this. (OBOS. nn 359)
19. I.V.F. - Intravenous fluids
20. Laminaria tent - It is a sterilised sea weed that absorbs moisture and expands, graduallv stretching
cervix. Helps softening and further dilatation of the cervix and reduces the chance of ccrvica!
injury and make the operation much easier.
21 LMP - Last normal menstrual period. (OBOS. pp 356)
22. Ungth of gestation / pregnancy - It is usually counted from the first dav of the LMP and not from
the day of conception (fertilization). (OBOS. pp 356)
G n° 01
Annexure 2.6
Glossary Notes
/
23. Maternity hospital - An institute for the care of obstetric patients. (Dorland's Medical Dictionary )
24. Menorrahhagia - Both, heavy’ bleeding and long periods (bleeding for more number of days)
together.
25. Missed abortion - Continued pregnancy (POC)- This is probable in early pregnancy , less than four
weeks after conception, six weeks LMP. The tissue removed from the uterus immediately after
abortion should be inspected to ensure that all pregnancy tissue has been removed. The abortion has
to be repeated in a week or so. (OBOS. pp 359)
26. MTP Act - Medical Termination of Pregnancy Act.
27. Parenteral fluids - Fluids injected through some other route, other than alimentary canal, as
subcutaneous, intramuscular, etc. (Dorland’s Medical Dictionary )
28. Perforation (POC) - It occurs if an instrument pierces through the uterus wall. The pulse, blood
pressure, cramping and bleeding arc closely monitored. The uterus generally heals quickly on its own.
However, if a large blood vessel or another organ is damaged, hospitalization and probably surgery’ is
needed. If abortion has been left incomplete due to perforation, it is finished in a hospital.
29. Polyclinic - A hospital and school where diseases and injuries of all kinds arc studied and treated.
(Dorland’s Medical Dictionary)
30. Postabortal Syndrome (Blood in the Uterus) (POC) - If the uterus docs not contract properly or if a
blood lot blocks the cervical opening and prevents blood from leaving the uterus, blood collects within
it resulting in pain, cramping and sometimes nausea increase. The clots can be removed either by
deep massage directly over the uterus or if this failsb by reaspirating the uterus. (OBOS. pp 359)
31. Primie - First pregnancy
32. Primie amcnorrhoea - Not getting the menses at appropritate age. this could be either congcntial
(which mostly arc difficult to attend to) or could be on account of anaemia and weak health status.
33.
Prostaglandin - Non-hormonal substance, formed widely in body tissues of both males and females,
from unsaturated fatty acids by the action of enzymes called prostaglandin synthetases. Natural
prostaglandin of medical use arc PGE2and PGF2.X
34. Quality 35. Retained tissue (POC) - Sometimes some tissue may be left behind after the abortion. Signs include
heavy bleeding, passage of large blood clots, strong cramps, bleeding for longer 3 weeks, signs of
pregnancy for more than one week. This tissue may get infected. To remove the tissue either
mctherginc or ergotrate arc given to stimulate the uterus to contract and push the retained tissue out
or aspiration procedure is carried out. (OBOS. pp 359)
36. Saline - Salt water (OBOS)
37. Suction - Drawing out the contents of the uterus through a narrow tube attached to a gentle vacuum
source. (OBOS)
38. Trimester:
First trimester - Il is the first thirteen weeks
■ Second trimester - It is the fourteenth through twenty-fourth weeks
. Third trimester - It is twenty-five weeks LMP and later (OBOS).
39. Uterine haemorrahge (POC) - It may occur in second trimester abortions due to retained tissue.
perforation or failure of uterus to contract. Drugs may be given to stimulate the uterine contractions,
or aspiration may be done to slow done the bleeding. (OBOS. pp 359)
40. Instruments used for abortion - (Diagrams will be added).
NOTES
1. Abortion procedures - (OBOS)
a) . Abortion by early uterine evacuation (EUE) • Pelvic exam confirms pregnancy
• Same technique as pre-emptive abortion except cannula size (5-6 mm) - flexible.
• Population control projects used this technique in Third World countries because it is easy to train lay
persons to do it and doesn’t require a motorised suction pump or much equipment.
b) . Pre-emptive abortion (endometrial aspiration) - This is an aspiration procedure
• 5-6 weeks
• Can be done without pregnancy test
• Smaller size cannulas (4-5 mm) - flexible
• No dilatation required, thus reducing the risk of perforating the uterus because of flexible cannulas
• Only a few minutes procedure
Annexure 2.6
Glossary rf- Notes
2
•
•
•
No anaesthesia required since no dilatation
No motorised pump required for suction. Only a syringe is used to create a vacuum
Test of Rh blood type are not part of pre-emptive abortions and Rh negative women are not usually
offered Rhogam.
c). Abdominal hysterotomy - It is a minor caesarean section. It is performed in some centres when
sterilization is wanted along with termination of mid-trimester pregnancy or in some cases of failure in
the induction of abortion (Chaudhari, 1996. pp 230)
In a hysterotomy, the surgeon removes the foetus and placenta through an incision into the abdomen and
uterus, like a small caesarean section. The incidence of serious complication for this kind of major surgery
is considerably higher than for other methods of abortion. It may be required when induction methods
have been repeatedly unsuccessful or can't be used for medical reasons. (OBOS. pp 358-359).
d) . Dilatation and curettage - It is a standard gynaecological procedure used to treat conditions such as
excessively heavy bleeding and to diagnose various uterine problems. It is usually done in a hospital under
general anaesthesia. Most commonly used for the first trimester abortion. Now it has virtually been
replaced by the quicker, easier and safer aspiration techniques which are usually done in clinics w ith local
or no anaesthesia. Some doctors will do a D & C for abortions from 12 to 16 weeks. (OBOS, pp 358).
e) . Dilation & Evacuation - It is newer method
method that
that combines
combines D
D&
&C
C and
and VA
VA techniques
techniques for
for abortions
abortions
later than 12 weeks LMP. (OBOS. pp 358)
f) . Induction abortion - The doctor injects (instills) an abortion causing solution through the abdomen
into the amniotic sac. which surrounds the foetus. Before sixteen weeks LMP this sac is not large enough
to be located accurately, so the induction procedure cannot be used until this time. Hours later,
contractions cause the cervix to dilate and the foetus and placenta to be expelled.
g) . Vacuum aspiration - removal of the uterine contents by application of a vacuum through a hollow
curct or a cannula introduced into the uterus. (Dorland's Medical Dictionary )
In this, cervical opening is stretched (dilated) so that a larger cannula can be used. An electricallv
powered aspirator is the source of infection. (OBOS. pp 357)
h). Hysterectomy - There arc certain situations where hysterectomy is preferable, e g., in elderly patients
with fibroid and often pelvic pathology, where ligation is not permitted by the church even after repeated
caesarean sections, where there are previous histories of menorrhagia. (Chaudhari. pp 231).
Hysterectomy can't be supported as a routine method of terminating second trimester pregnancy where
sterilization is required.
i). Opposite views - Use of D & E in ST :
OBOS - They arc in favour
Chaudhari - He is not in favour
Woman should be given a choice if the provider can provide D & E (i.e., he has the required competence)
and environment and the facilities.
j). Second trimester procedures - Advantages of D & E over induction :
• D & E is safer
• It is physically easier for a woman than an induction abortion, where she goes through labour and
delivery of a foetus, often in a hospital room all by herself.
ind^cdonTbortion)^ (1°"15 H1'"5 C°mparCd t0 many h0UrS with an ovcrn'8ht sta.v '» a hospital for
wilt tranqmiscT
3 Pr0PCr‘y
' Ofr,CC Or C',niC
1001 anacslhctlc and Perhaps also
Annexure 2.6
Glossary dir Notes
3
Abortion procedures
Surgical
Medical
First Trimester______________
Vacuum Aspiration
D&C
D&E______________________
Induction method
using prostaglandin
as a . smooth muscle
stimulant / priming
agent (to alter and
soften the structure of
cervix)
. luteolytic agent
inhibiting progesteron secretion
of corpus luteum (not yet being
used in human beings)
Second Trimester________________
D&E
Hysterotomy
Hysterectomy_____________________
Induction by using either - Drugs (Hypertonic saline, urea.
cmcrcdil. rivanol. ethacridinc lactates.)
cither
. Intra-amniotically or
. Extra-amniotically or
. Trans-cervically or
. Trans-vaginally
- Devices
- Combined procedures using different
combinations of drugs and devices.
2. Abortion equipment a). Opposite view s : Use of flexible / non-flcxiblc cannulas
Abortion procedure - Vacuum Aspiration (VA)
Source OBOS - Women's group feel the need to develop the safest, least physically traumatic VA
techniques. Prefer minimal dilatation and small flexible cannulas reducing the chance of tearing or
perforating the uterus or cervix. Experience at these clinics show that this approach is more comfortable
for women than that of most conventionally trained abortionists, who use larger, rigid plastic or metal
cannulas (which require more dilatation and curette after the suction).
Source Dr Chaudhari S.K., Practice of fertility control - For VA non-flcxiblc plastic cannulas arc
preferable to the flexible Karman type of cannula because the latter stick to the uterine wall, the smaller
holes are often choked with uterine contents and sometimes the tips arc snipped off. Chaudhari prefers the
metal cannulas because they can be sterilized by boiling for half an hour and can be used repeatedly,
involves less cost.
Rigid plastic cannulas can be used repeatedly for 25 operations. Plastic cannulas can be sterilized by
immersing them in a weak aqueous solution of povidine-iodine (1:2500) |Betadine solution of a definite
orange colour, not yellow' or brown | or other antiseptic solution (2% cctrimidc in water) for about 20
minutes.
b). Electric suction machines - (Bcrclay is the best one) - locally made machines arc also available.
• Suction machine used by the anaesthesists in the operation theatre also could be used.
• Hand pump / foot pump sets may be used where electricity is not available or power fails.
• Suction apparatus must produce atlcast 25 inches or 625 mm Hg negative pressure during operation.
• Set should be checked pre-opcrativ ely and must be leak proof.
Reporting of the MTP cases : PHCs are expected to report the MTPs to the ZP whereas the private sector
(from the whole district) reports to the DHS, Pune Circle in case of Pune. In case of Ratnagiri district
both, private and public are supposed to report to ZP.
Sterilisation
aicniisauon : There
i here are two methods of sterilisation. They are autoclaving and boiling. Both arc equally
good. Except the fact that certain things, such as. plastic material, cloth, gloves etc can't be boiled for
obvious reasons. Either autoclave machines or pressure vessels/cookers are used for autoclaving.
References:
1. Petchcsky Rosalind Pollack. 1990, Abortion and Woman's Choice: The State, Sexuality and
Reproductive Freedom, (Revised edition). Northeastern University Press. Boston.
2. Chaudhari S.K.. 1996, Practice of Fertility Control A Comprehensive Textbook, (Fourth Edition).
B.I.Churchill Livingstone Pvt. Ltd.
3. The NewOur Bodies. Ourselves : A book by andfor women. 1992. Simon & Schuster Inc. New York.
London. Toronto. Sydney. Tokyo. Singapore.
^inexure
(ilossary.d- \otes
7
c:\siml\reap\repor(\annex\protocol.ann, Sep 30,97; Dec. 14, ‘99
zknnexure
5
PROTOCOL AND GUIDELINES
FOR THE RESEARCH TEAM MEMBERS/LNVEST1GATORS.
The guidelines laid down for the researchers/investigators were basically to maintain consistency and
uniformity during data collection. The efforts were to made to minimise individual biases. They couldn’t
be eliminated completely yet by strictly following the guidelines, we tried to minimise them It had
special significance m the present case since a large portion of the data collection were through
observation.
Following were the guidelines laid lor field researchers while administering various interview
schedules
General
•
°f 016 interviewer/0bserver> "urcber of visits and the’date of interview must be entered
cieariy.
There is a set of interview/observation schedules to be administered at
one single unit of the study, n
case HI and the provider are the same persons.
Even otherwise we have obtained these information from HI in ‘personnel (Q No
hi case of gnarl hospital/polyclinic/cooperative/corporate/civil hospital (any setup which has more
an one doctor/medical providers) the interview schedule designed for the provider should be
administered with the one who provides abortion services. Please cover all the abortion providers in
case there are more than at a particular centre.
P
Please pose the question the way it has been framed.
‘
nature of 016 questions t0 reduce ‘after efforts’required for data cleanins
•
•
’ ' Flit TPlat,nin8 3 qU,eStT SmCe 11 may intr°dUCe lnvestl8ator< biases while posing the question
Please don t skip or alter the sequence of the questions, unless mentioned
• li any other , please specify.
• Daily protocol should be maintained.
Ideally there should be daily discussion after the field work which may not be possible but meetince twice a week is essential to discuss problems and experiences during the field work
Guidelines for researchers while administering
‘Interview schedule for Head of the institution (HI)’:
centre (PHC), Rural
Q no 7 : Structure of the institution : Maternity hospitals are those medical
care service centres which
provide obstetrics and gynaecological health care services ’ ’ ’
which include delivery' care, antenatal care
Pu0Str?tal Care (PNC)’ gynae“log>eal illnesses under
—: one roof. Many a times it may have
paediatric health care facilities, too.
General hospitals are those which provide more than
one specialised health care services including
obstetrics and gynaecological health care services
Annexure 2. 7
Protocol & Guidelines
1
Q No 11 : Qualifications : Pl record the actual degree told by the provider and then tick the relevant
category. Pl clarify, in case of any doubts about the system of medicine ot his qualifications and level of
his training in medical care. Specialisation should get recorded.
Q No 13 : Ownership of the institution :
5. Corporate hospitals are those which are sponsored/looked after by the companies These
hospitals arc profit making
6. Cooperatives hospitals are those which are supported by shareholders. Benefits and
losses are shared among the shareholders
3. The trust hospitals are registered as trusts under the trust Act. There are trustees and
beneficiaries and are run on no profit no loss basis.
4. The society hospitals are registered bodies as a society. These too are run on no profit,
no loss basis and is more democratic in its style of function.
These hospitals thus are different from each other mainly in terms of rules and regulations which are
guided by the respective Acts under which they are registered. This may have bearing on their policies
about charges for the medical care they provide, subsidies, mode of drug supply etc.
NGOs could be either trusts or societies.
Q No 16 : Personnel : 1. Doctors : Pl. record all the doctors, get information on sex, age and
qualifications and their mode of associations with the centre (attached/on call/employee/uses this set up
to attend his cases, especially those requiring operatives and admissions). Then get information on who
all from among these conduct abortion at the centre and tick against them. Ask ‘training’ in abortion
only for abortion providers who are non-gynaecologists. Here we have to be specific about abortion
training.
Q no 19 : Up to what length of gestation abortion services are provided
It the respondent mentions only up to 12 weeks, pl enquire if the centre ever attends abortion cases of
more than 12 weeks
Q No22 : Mode of drug supply : In case of ‘3' pl confinn if there is no replacement system of either all
or essential drugs. If response is ‘prescription’, it should be categoried as ‘3 - no drugs are supplied inhouse1 only after confirming about replacement
Ranking exercises : For example Q No 23 about the cost determinants
Hand over the set ot cards to the respondents. Once s/he ranks them in descending order record the serial
nos of the determinants written at the back of the card in the table here against the respective pre-typed
ranks in the table.
Q No 39 : Registration status : -mhe-centfestatus
IVhich centres could be categorised as Non-registered abortion service centres ?
The centre is registered, but the providers are not qualified in formal sense (they are nongynaecologists and do not have any training as per the Act) but do have skills to conduct abortion since
they are conducting abortion for long or they have acquired such training in informal setup but in equally
good setup, that is, they are qualified in practical sense)
The centre is registered, but the providers are not qualified, that is, they are
non-gynaecologists and
do not have any training as per the Act either formally or informally. Thus are
not qualified either in
formal or practical sense.
Annexure 2.7
2
Protocol & Guidelines
The centre is not registered, the providers are qualified (gynaecologists - ML), Gyneacologist, MDBS,
DGOs etc.) or trained as per the need of the MTP Act (...... )
The centre is not registered, the providers are not qualified in formal sense (they are non
gynaecologists and do not have any training as per the Act) but do have skills to conduct abortion since
they are conducting abortion for long or they have acquired such training in informal setup but in equally
good setup (that is they are qualified in practical sense).
The centre is not registered, and the providers are not qualified, that is, they are non-gynaecolegists
and do not have any training as per the Act either formally or informally. Thus are not qualified either
in formal or practical sense. (This includes ANMs, PHC doctors providing abortions at their own place,
private practitioners and also local abortionists in conventional sense)
Guidelines for researchers while administering
Interview schedule for provider
Q No 8 : Qualifications
Pl record the actual degree told by the provider and then tick the relevant category. Pl clarify, in case of
any doubts about the system of medicine of his qualifications and level of his training in medical care.
Specialisation should get recorded.
Q No 15 : Preference to a particular method :
If the respondent does not respond with reference to the other methods of abortion, the probe could
include names of these methods that are mentioned in the table here to get more focused response. For
example : Respondent has said VA/SC is used. The probe could be ‘The methods such as D & C and D
& E are also used for abortion up to 12 weeks. Why do you prefer VA/SC particularly?’
Also if respondent says that s/he prefers a particular method because it is ‘well accepted method’, probe
to understand as to why is it ‘accepted’ .
Q No 34 : lUCD/sterilisation compulsory' or mandatory':
In case the respondent says that s/he does insert IUCD immediately alter abortion (Q 26) then restrict the
Q No 34 only to whether sterilisation is mandatory and don’t ask whether IUCD is mandatory.
Annexure 2. 7
Protocol & Guidelines
3
An nexu re
6
THE MEDICAL TERMINATION OF PREGNANCY ACT, 1971
|No.34 OF 1971]
{IO'1'19711
An Act to provide for the termination of certain pregnancies by registered medical practitioners and for
matters connected therewith or incidental thereto.
Statement of Objects and Reasons - (1) The provisions regarding the termination ofpregnancy m the Indian Penal Code which were enacted
about a contury age were drawn up in keeping with the Hntish Law on the subject. Abortion was made a crime for which the mother as well as the
abortionist could be punished except where it had to be induced in order to save the life of the mother. It has been stated that this very strict law
has been observed m the breach in a very large number of cases all over the country. Furthermore, most of these mothers are married women,
and are under no particular necessity to conceal their pregnancy.
(2) In recent years, when health sereices have expanded and hospitals are availed of to the fullest extent by all classes of society, doctors
have phen been confronted with grayely ill or dying pregnant women whose pregnant uterus has been tampered with a view to causing an
abortion and consequently suffered very severely.
(3) There is thus avoidable wastage of the mother's health, strength and. sometimes, life. The proposed measure which seeks to liberalise
certain existing provisions relating to termination ofpregnancy has been received (1) as a health measure - when there is danger to the life or
risk to physical or mental health of the woman. (2) on humanitarian grounds - such as when pregnancy arises from a sex crime like rape or
intercourse wirh a lunatic woman, etc., and (3) eugenic grounds - where there is substantial risk tnat the child, if born, would suffer from
deformities and diseases. - CwMe of India. Pt. II. Section 2. Extra, dated November 1~. 1969. p.880.
Be it enacted by Parliament in the Twenty-second Year of the Republic of India as follows
1. Short title, extent and commencement - (1) Ihis Act may be called the Medical Termination of Pregnancy Act 1971
(2) It extends to the whole of India except the State of Jammu and Kaslunir.
(3) Il shall come into iorce on such date as the Central Government may. by notification in the Official Gazette, apjxnnt
2. Definitions - In this Act. unless the context otherwise requires, (a) “guardian” means a person having the care of the person of a minor or a lunatic.
(h) “lunatic” has the meaning assigned to it in Section 3 of the Indian Lunacy Act, 1912 (4 of 1912),
(c) "minor means a person who, under the provisions of the Indian Majority Act. 1X75 (9 of 1875), is to be deemed not
to have attained his majority.
(d) “registered medical practitioner” means a medical practitioner who possesses any recognised medical qualification as
defined in clause (h) of Section 2 of tlie Indian Medical Council Act, 1956 (102 of 1956), whose name has been
entered in a State Medical Register and who has such experience or training in gynaecology and obstetrics as ma\ Ik*
prescribed by rules made under this Act.
NOTES
Though die Indian Lunacy Act defines “lunatic” as an idiot or a person of unsound mind, the said words have not been defined. Both these
words indicate an abnormal slate of mind as distinguished from weakness of mind senility following old age. A man of weak mental strength cannot be
callai an idiot or a man of unsound mind. The definition does not include dull-whled people but only those who suffer from a mental disorder or
derangement of the mind. Ganga Bhavanamma v. Somaraju. .AJR 1957 AP 938.
“t'nsoundiess of mind" implies some unusal feature of the mind as has tended to make it different from die normal and has in effea impaired die
nun s capacity to kx>k after his affairs in a manner in which another person without such mental irregularity would be able to do in the matter of his
own. The idea suggests some derangement of the mind and it is not to be confused widi or taken as analogous to a mere mental weakness or lack of
intelligence. Sarjug Singh v. Gulabo Kuer. AIR 1969 Pat 33.
No person can have direct ex^xnenoe of the mind of another and the proper test of insanity is conduct. A person might conceivably have all kinds of
delusions, but if his conduct remains normal there would be no justification for holding him to be lunatic Abdul Razak v. Commissioner of Income
Tax. AIR 1935 pat 425.
If a nun is able to underhand and answer questions on various matters except those relating to arthmetical calculations, he cannot be regardeii
mentally unsound althou^t he would be held as having a weak or undeveloped mind. Joshi Ram Krishan v. Rukmini Bai. .-MR 1949 .411 449. '
I ndcr Indian Majority Act, 1875. a person in respect of whose person or property a guardian has been appointed by a court of justice or a peruxi who
is under the jurisdiaioo of Court of Wards attains majority on the conplction of twenty first-year and in all other cases a person is deemed to attain Ute
age of nujority on the completion of eighteenth year.
the lndianPPenal Code
nK'll.lt!'' l’nic(i,ill,K'rs ~ (I) Notwithstanding anything contained' in
of IS^'^reeis^r^m
under anv other law for the time beine in fir - T
11,1 l’r'IL '.tll’ller slul11 1101 ,ie f11'11?
any olfence under dial Code or
Act
''g
11 i,nv l^Tnancy is lennmated by him m accordance w ith the provisions of tins
.T
"“h- ........ .. ...............
'"d" ..................
of opinion, formed in good faidt, that -
(i)
t^h^hZ'ortXT^hh; orWU'd inV°,VC “
(ii)
^Ihiesasta^sSouS'kmd^^
‘0 ‘b* b* °f
Prc£1’a,U
k”1'’ “ "0Ul''
,Y0"'
or mental
caused bvX" ' S^ZsSto co^n^ b>'
'VOn,an 10
tausdd b>'
11 ^Ptcstatied to constitute a grave iniury to the mental health of the pregnant woman.
woman orStS forSdn?d^"" £ 0 ^"f't °f li,ikW °f ai»'
be presumed to constitute a pSjury to thememal hrainTof'wwmn’
w
b>
used by am .named
Un"'an‘e<1 !’n*na"J
......
woman.
“°
Pr°'ldCd m C'aUSe fo)' n0
shall be terminated except with the consent of the pregnant
bC ,Crmina,Cd- - No
01 pregnancy shall be made in accordance with this Act at
(a) a hospital established or maintained by Govenunent, or
(b) a place for the tune being approved for the purpose of this Act by Govenunent
Section 3 as relate to
°f
apply to die termination of a pregnancy ^TrZ^er^mcZ?
lio" 4’ and 50 n’uc1’
r,
,W°
provisions of sub-s^tion (2) of
mediCal Prac'i'i™rs, shall not
“ ,,4!Jr
r™.
extent, stand modified.
• >««-» b •
oficncc punishable under dial code, and that code shall, to litis
Explanation. - for die purpose of this section, so i
of the provisions of clause (</) of Section 2 as relate to lite possession
by a registered medical practitioner, of experience much
or
- training tn gxitaecology and obstetrics shall not apply.
.NOTES
done or betieccd wiihol due care md attfuk^ Cnd^the
cfnd'a" v"111
Nod''"S '* Sa'd 10 bc dc"e or bei'e'ed in
f’Wi whidi is
<fa» hoiifldly uhoher it is done negligently or not". 71,c elaiu^t of liai'«v\d,id,'' ’i’3" n.‘leC"K'd k' d°"c good
''l’eTe " "
Ad is not mtrodueod by the definition probed by section 32 ofthc tod cXfe
l"lr‘'du-''d b.' the definition prescribed by the General Clauses
in the absence of personal malice it will hareto be'dwnlha't th
1
‘i"1! bU' 'L' s's”'fican'x’or ""Ponance cannot be exaggerated. Firn
1966 SC 97 1966 Cn U 8:.
l,'3, the M was do"'-- «")> due eare and attention, flarbiiajan Smgh v. Slate oTPun^R
Due care and aaanicu implies a {
gomme etfon to read, U,e
quesitn of last and niust be gathered front die surrounding a”n
.
i't
-dv a^dame dlman,,^ M,ef lhe qneaion of good fa,th ,s a
;.XI:Te a1jual Wld, ",Ihl’ul
teas.,,able grounds for hdievu.g is'
A lack of deligenee uhidi an honest man or c.
’
ordinary
prudence’s
sound judgement, llarbhajan Sin^Tstatc
•«‘lb in Peril of inflate d,
. « ill be io nuke die « onun a plrn^OT nStr^k
a«h?X'iaT U
>™«Kw.TO.i5^lingforu1epu^ofp^“rg^a1i^f;:e“
« no, a conau okan.ed
«o Mieve
U.e
T1” l'' ""S,!<lua,“ of U,e ™'«i>>uance c,r
of die pregpincy
™iccs and in diat
« on od^ae
implied consent to suffer die harm and to take
Mm'w,"° "’a,’ ----senses would dare to apply, die ^onsait
good faW,. Tuggankl)an
proSs'ol-UUsYct.1'5' ’(1} 7116 Cenlral Govcnmenl -W, by notification in the Otficial Gazette, make rules to cam ^ut the
10
U>e tbfi^nSS
g"‘>
l>o\ver, such rules may provide for all
or any of
a)
b)
lhe experience or training, or both, which a
registered medical practitioner shall have if he intends to tenninate
any pregnancy under this Act; and
such other matters as are required to lx.or may be, provided by rules made under this Act.
before each House' of ParliamentwhiiJiurta KssionTr a totaTnu^f
la'd' “ SO°" 35 maV
aller il is nlullc’
or m two successive sessions, and if. before the expirv of the session i^ridh'v
" hlCh ",a-V >« “'“Prised in one session
both Houses agree in making any modification in The rule or both
t o S° a‘d °r Q'C 56551011 ilnmediate|y following,
thereafter have elTect only in such modified form or be of no effect as th •
latJ1C "'u Sll°U!d n01
made’ ,1'c nlle sVal1
or annulment shall be without prejudice to the validity of anythingm<X,i,1Ca,S01'
7. Power to make regulations. -(1) The State Government mav. by regulations -
—,ira,«
this Act.
y
*V anythln8 uh,ch ,s ,n
*******
13,111 d°ne or intended to be done under
MEDICAL TERMINATION oe pregnanca
RULES, 1975
Central ^ovenX.XXniak^heklllmo X''llll"1 Tvrmi"i"i,m ,,f'’'^'ncy Ac., 1971 ,54 of 197! ,
the
1. Short title and commencement. - (|) Giese rules
1975
may Ik- called the Medical Termination of I’rcgnancv Rules,
(2 > Iliev shall come into force on die date of their publication in the OlTicial Cuizette.
2. Definitions. - In these rules, unless the context odierwise requires
1971 (34 of 1971);
fb
U
.. .
or otherwise responsible for the
(e)
(f)
Section means a section of the Act.
Experience
one or5 more
of the fX^^ or
mCdira' PraC,i,iOner Slli'1' haW
t,crxin a s,a,rMedicai
experience tn the prachce of gynaecology and obstetrics for a period of not less than
praCtili°ner wh0 was «gia‘ered in a State Medicial Register on or after the dat^oflhe |
three years;
(2 Xe he InsiiolX^ ,nOn,1’r’/house
»’ gynaecology and obstetrics ; or
les that on!’ vX in he
7 7 7'“ SUrgCnCy'lf l,C had
al
'Wital for
a period of not
css that one y ear in the practice ol obstetrics and gynaecology or
.kj,i
sssskt" ”
purpose, by the Government.
°r ,na’nk,incd’ or a lr««ning institute approved for this
*
(c) tn the case of a medical practitioner who has been reaistered in n
State Medical Register and who holds a ^stgraduate degree or diploma m gsmaecology and obstetrics, the ex£rience or
trainmg gained during the course of such degree or
4 APPr0'X 11 P'X ;'1 ’ N° P,aCC ShaI1
aPProvcd
clause (6) of Section 4 conTtiXX”' 'S Sa,iSfied tha‘lCnninaliOn Of P^“
therein under safe and hygienic
(») tutless the following facilities are provided therein, namely
omlX-mPP!Xti0n l0r the aPProval ol'a place shall be
in a I-onn A and shall be addressed to the Chief Medical
Olhcer of the District
any mlonnation contained in any such application or inspect al slh pl
th
'SlnCt Sha" Ven‘V °r e"‘|uire
reteired to in sub-nrle (1) are provided Uterein and
>
r
3 V‘eW '0 Salisfy h"nscll',ha> the facilities
hygienic conditions.
’ d"d that ten,’"'at'™' <>t pregnanc.es may be made therein under safe and
(4) Even owner < * ‘
facilities for the inspection of the place.
r**
nt* «L .
.. I
Chief Medical Ollker of the District shall afford all
'
considered nec-essa^to LniLnaUon of pa'g'XierntaX doX"
Ute approval of such place to the Government.
'
reasonable
sudt verification, enquiry or inspection, as may be'
d
C and ,,yg,en,c Hiltons, at the place, recommend
(6) The Government may after considering (he application and the recommendations of the Chief Medical OlTicer of
the District approve such place and issue a certificate of approval in Form B.
(7) The certilicate ot approval issued b\ the Govenunent shall be conspicuously displayed at the place to bexeasilv
visible to persons visiting the place.
5. Inspection of a place. - (1) A place approved under Rule 4 maydx' ins|>ected by the Chief Medical Officer of the District, as
often as may be necessary with a view to verity whether tennination of pregnancies is being done therein under safe and
hygienic conditions.
(2) It the Chief Medical Officer has reason to believe that there has been death of, or injury to, a pregnant Woman at
the place or that tennination of pregnancies is not being done at the place under safe and hygienic conditions, he may call for
any intonnation or may seize any article, medicine, ampule, admission register or other document, maintained, kept or found at
the place.
'
(3) The provisions ot the Code ot Criminal Procedure, 1973 (2 of 1974), relating to seizure shall, so faf as may be,
apply to seizures made under sub-nile (2).
6. Cancellation or suspension of certificate of approval. - (1) If, after inspection of any place approved under Rule 4, the
Chiet Medical Officer ot the Distnct is satisfied that the facilities specified in Rule 4 are not being properly maintained therein
and the tennination of pregnancy at such place caimot be made under safe and hygienic conditions, he shall make a report of
the tact to the Govenunent giving the detail of the deficiencies or defects found at the place. On receipt of such report the
Govenunent may, after giving the owner of the place a reasonable opportunity of being heard, either cancel the certificate of
approval or suspend the same for such period as it may think fit.
(2) Where a certificate issued under Rule 4 is cancelled or suspended, the owner of the place may make such additions or
improvements in the place as he may think fit and thereafter, he may make an application to the Government for the issue to
him ot a fresh certilicate ol approval under Rule 4 or, as the case may be, for the revival of the certificate which was suspended
under sub-rule (1).
'
(3) The provisions of Rule 4 shall, as far as may, apply to an application for the issue of a fresh certificate of approval in
relation to a place, or as the case may be, for the revival of a suspended certificate as they apply to an application for the issue
of a certificate of approval under th^t rule.
(4) In the event of suspension of a certificate of approval, the place shall not be deemed to be an approved place tyr the
purposes of tennination of pregnancy from the date of conununication of the order of such suspension.
7. Review. - (1 >The owner of a place w ho is aggrieved by an order made under Rplc 6, may make an application for review of
the order to the Govenunent within a period of sixty days from the date of such order.
(2) The Government may, after giving the owner an opportunity of being heard, confirm, modify or reverse disorder.
8. Form of consent. - The consent referred to in sub-section (4) of section 3 shall be given in Form C.
9. Repeal and saving. - The Medical Tennination of Pregnancy Rules, 1972, are hereby repealed except as respects things
done or omitted to be done before such repeal.
FORM A
|See sub-rule (2) of Rule 4 ]
Form of application for the approval of a place under clause (b) of Section 4.
1.
2.
3.
4.
Name of the place (in capital letters)
Address in full
Non-Govenunental/Private/Nursing home/Other Institufions*.
State, if the following facilities are available at the place:
(/) An operation table and instruments for perfonning abdominal or gynaecological surgery.
(ii) Drugs and parenteral Quid in sufficient supply for emergency cases.
(in) Anaesthetic equipment, resuscitation equipment and sterilisation equipment.
Place:
Date
•Strike out whichever is not applicable.
Signature of the owner of the place
FORM B
|.See sub-rule (6) of Rule 41
Certificate of approval.
C4
' 197^1C
^cscr'^c^ below is hereby approved lor the purpose of the Medical Termination of Pregnanes Act,. 1971
Name of the Place
Address and oilier descriptions
Name of the owner
to the Government of the
Place
Date
FORM C
[See Rule 8]
I
da ugh ter/wife
of
aged
alxnil
sears of
(here slate the permanent address)
at present residing at
do hereby give my consent
to the termination of my pregnanes at
(State the name ot place where the pregnancy is to be terminated)
Place:
Date
Signature
(To be filled in by guardian where the woman is a lunatic or minor)
I
about
son/da ugh ter/wife of
sears of
aged
at present residing at
(Permanent address)
do hereby give my consent to the termination of the ’pregnancy of my ward
who is a
minor/lunatic at
(place of termination of pregnanes)
Place:
Date
Signature
*****
.MEDICAL TERMINATION OF PREGNANCY REGULATIONS, 1975
t
In exercise ol the powers conferred by Section 7 of (he Medical Termination of Pregnancy Act, 1971 (34 of 1971).
the Central Government herebx makes the following regulations, namelv : 1. Short title and commencement. - (I) lhesc regulations may be called the Medical Tennination of Pregnancy
Regulations, 1975.
(2) They extend.to all the Union territories.
(3) They shall come into force on the date of their publication in the Official Gazelle.
2. Definitions. - In these regulations, unless the context otherwise requires (a) “Act” means the Medical Tennination of Pregnancy Act, 1971 (34 of 1971).
(b) “Admission Register” means the register maintained under regulation 5;
(c)
Approved place” means a place approved under Rule 4 of the Medical Tennination of Pregnancy Rules,
(d)
Chief Medical Ofticer ot the State” means the Chief Medical Officer of the Stale, by whatever name
called;
(e) “Fonn” means a form appended to these regulations;
(0 hospital means a hospital established or maintained by Ute Central Government or the Government of the
Union territory;
■ ’
(g) “section” means a section of the Act.
3. Form of ccrtihing opinion or opinions. - (1) Where one registered medical practitioner forms or not less than two
registered medical practitioners fonn such opinion as is refened to in sub-section (2) of Section 3 or Section 5, he or they shall
certify such opinion in Fonn I.
(2) Even registered medical practitioner who terminates any pregnancy shall, within three hours from the tennination of
the pregnancy certify such termination in Fonn I.
4. Custody of forms. - (1) The consent given by a pregnant woman for the tennination of her pregnancy, together with
the certified opinion recorded under Section 3 or Section5, as the case may be and the intimation of tennination of pregnancy
shall be placed in an envelope which shall be sealed by the registered medical practitioner or practitioners by whom such
tennination ot pregnancy w'as performed and until that envelope is sent to the head of the hospital or owner of the approved
place or the Chief Medical Officer of the State, it shall be kept in the safe custody of the concerned registered medical
practitioner or practitioners, as the case may be.
(2) On every envelope referred to in sub-regulation (1), pertaining to the tennination of pregnancy under Section 3, there
shall be noted the serial number assigned to the pregnant woman in the Admission Register and the name of the registered
medical practitioner or practitioners by whom the pregnancy was terminated and such envelope shall be marked “SECRET’.
(3) Every envelope referred to in sub-regulation (2) shall be sent immediately after the termination of the pregnancy to
the head of the hospital or owner of the approved place where the pregnancy was tenninated.
(4) On receipt ot the envelope referred to in sub-regulation (3), the head of the hospital or owner of the approved place
shall arrange to keep the same in safe custody.
(5) Even head of the hospital or owner of the approved place shall send to the Chief Medical Officer of the Stule. a
weekly statement of cases where medical termination of pregnancy has been done in Form II
(6) On eveQ'jenvelope referred to in sub-regulation (1), pertaining to a termination of pregnancy under Section 5, shall
be noted the name and as address of the registered medical practitioner by whom the pregnancy was terminated and the date on
which the pregnancy was terminated and such envelopes shall be marked “SECRET”.
Explanation. - The columns pertaining to the hospital or approved place and the serial number assigned to the pregnant woman
in the Admission Register shall be left blank in Form I in the case of termination performed under Section 5.
(7) Where the Pregnancy is not tenninated in an approved place or hospital, even envelope referred to in sub-regulation
(6) shall be sent by registered post to the Chief Medical Officer of the State on the same day on which the pregnancy was
tenninated or on the working day next following Ute day on winch the pregnancy was tenninated:
Provided that where the pregnaimey is terminated in an approved place or hospital, the procedure provided m subregulations (1) to (6) shall be followed.
>. Maintenance of Admission Register - ( I ) Every head of the hospital or owner of the approved place shall
maintain a register in Form III for recording therein the admissions of women for the termination of their pregnancies
(2) ThC- entries in the Admission Register shall be made serially and a fresh serial shall be started at the
commencement ol each calendar year and the serial number of the particular year shall l>c distinguished from the serial numlK-i
b> n!cntionin& lhe >car a8ainst the serial number, for example, serial number 5 of 1972 and serial number 5 of
1973 shall be mentioned as 5/1972 and 5/1973.
(?) The Admission Register shall be a secret document and the information contained therein as to the name and
other particulars of lhe pregnant woman shall not be disclosed to any person.
a 6'Adr",ss,on Register not to be open to inspection. - The Admission Register shall be kept in the safe custod)- of
the head of the hospital or owner of the approved place, or by any person authorised by such head or owner and save as
au^rit^or0™^ in Suh'regulatl0n
of Regulation 4 shall not to be open to inspection by any person except imdyr the
(/) in lhe case ot a departmental or other enquiry, the Chief Secretary to die Government of a Union terrilorv.
(//) in the case of an investigation into an offence, a Magistrate of the First Class within the local
limits or
whose jurisdiction die hospital or approved place is situated.
(in) in the case of suit or other action for damages, die District Judge, within the local limits of whose jurisdiction
lhe hospital or approved place is sijuated.
Provided that lhe registered medical practitioner shall, on the
whose pregnanes
the application
application of
of an
an employed
employed woman
woman whose
prcgnanc\
the purpose
purp
has been terminated, grant a certificate for die
of enabling her to obtain leave from her employer:
Pnnided further that any such employer shall not disclose this information to any other person.
7. Entries in registers maintained in hospital or approved place - No entry shall be made in any
register; rollow-up card or any other document or register (except die Admission Register)
mamtomed at an) hospital or approved place indicating therein the name of the pregnant woman and reference to the pregnant
woman shall be made therein by the serial number assigned to such woman in the Admission Register.
I Ini^n f 8;, Dcst™ct,on of Admi5sion Register and other Papers. - Save as otherwise directed by the Chief Secretary to the
r'?,r^ral,0,, °r l0Ar;n.relal,0n to an> Proceeding pending before him, as directed bv a District Judge or a
FY S aSS’_ ever> Admiss,on Register shall be destroyed on the expin' of a period of five years from the lite
of the last entry in that Register and other papers
pregnancy concerned
' * ? °n
CXpiry 01 a P01-’^ 01 lhrec years from die dale of die termination of the
FORM I
(See Regulation 3)
(Name and qualification of the Registered Medical Practitioner in block letters)-------------------------(Full address of the Registered Medical Practitioner)
~————————---- - --------------------------
I
(Name and qualification of the Registered Medical Practitioner'in block letters)------- ------------------------- ------------------------(Full address of the Registered Medical Practitioner) hereby certify that • I/we/am/are
is necessary to terminate the pregnancy of
(Full name ol pregnant women in block letters)
resident of
__ ______
(Full address of women in block letters)
for the reasons given below*•.
fonned in good faidGtou
Place:
0
Signature of the Registered
Medical Practitioner
Date
Signature of the Registered
Medical Practitioner
• Strike out whichever is not applicable.
** ol the reasons specified items (/) to (v) write the one which is appropriate: (/) In order to save the life of the pregnant woman.
(ii) In order to prevent grave injur)’ to the physical or mental health of the pregnant woman.
(Hi) In view ot the substantial risk that if the child was bom it would suffer from such physical or mental
abnonnalities as to be seriously handicapped.
(/v) As the pregnancy is alleged by pregnant w'oman to have been caused by rape.
(v) As thee pregnane) has occuned as a result ot iailure of any contraceptive device or method used by the ntarried
woman or her husband for the purpose of limiting the no. of children.
Account may be taken ot the pregnant women's actual or reasonably foreseeable environment in
determining whether the continuance of a pregnancy would involve a grave injur)' to her physical or mental health.
FORM H
[See Regulation 4 (5)J
I.
Name of the State.
2.
Name of Hospital/approved place.
3.
Duration of pregnancy (give total No. only)
a) Upto 12 weeks
b) Between 12-20 weeks.
Religion of w<oman.
a) Hindu
b) Muslim
c) Christian
d) Qthers
e) Total
5.
Termination with acceptance of contraception.
a) Sterilisation
b) I.U.D.
6.
Reasons for termination : (give total number under each sub-Jiead).
a) Danger to life of the pregnant woman.
b) Grave injur)' to the physical health of lite pregnant w oman.
C)
Grave injur)' to the mental health of the pregnant w-oman.
d) Pregnancy caused by rape.
e) Substantial risk that if the child w'as bom, it wwld sutler from such physical or mental abnonnalities as to be
seriously handicapped.
0 Failure of any contraceptive device or method.
Signature of the OiYicer
Incharge with date
SECRET
c.
FORM 111
I.See Regulation S ]
ADMISSION REGISTER
(1 o be destroyed on die expiry of five years from die date of die Iasi entry in die Register)
S. No
Date of Admission
Name of Patient
Wife/]Slighter of
Age
Religion
2
3
4
5
6
1
Address
7
Duration of
Pregnancy
8
Reasons on which
>regmmcy is terminated
9
Date of discharge of
patient
Result and
Remarks
11
Name of Registered Medical
Practitioner(s)by whom the opinion
is formed
12
*«*••
Date of termination
of pregnancy
10
Name of Registered Medical
Practitioner by whom pregnancy is
______ terminated
14
ANNEXURE7
Letter of Introduction to the Respondents
Dear Dr
Greetings! We are a research centre of Anusandhan Trust, a non-profit educational trust. The research centre
CEHAT (which in Hindi means health) is working in health and related areas. The various areas in health
research that are flourishing in our institution are women’s health; health economics; health legislation, ethics
and patients’ rights, and law; health and human rights; medical ethics. On each of these themes CEHAT is
committed to do Research, Action, Service and Advocacy.
We have been working on abortion issue from rural women’s perspective for last three years. One of the
major areas, which came into focus very sharply, was about women’s perceptions, which are based on their
experiences about abortion facilities. This required us to take up a research programme with abortion
providers to understand their views about this sensitive issue, especially focusing on existing abortion
services vis-a-vis areas and scope of improvement so as to facilitate woman's access to abortion. We have
appreciation for abortion providers who face odd situations on number of account, be it counselling services to
woman or dealing with government authorities and bureaucrats. Providers’ initiative in offering abortion
services is valuable for obvious reasons. When we tried to understand one side of the coin - women’s
perspective - it is equally important to get back to providers to understand and feel the problems they are
facing while providing abortion services at various level, such as, lack of resources, especially in rural areas,
legal restrictions and cumbersome procedures involved in registration formalities and lack of co-operation
from government inspecting authorities. Lack of safe abortion facilities has direct bearing on increased
mortality and morbidity in abortion we all together have to work towards providing and assisting to provide
safe abortion services.
This meeting with you constitutes part of survey being conducted to locate abortion service centres. We are
here to seek your cooperation in locating abortion providers and if you provide such services we will get back
to you soon for an interview. Your participation in the study is much appreciated and welcome. It is valuable
not only for data collection but for each one of us who is associated to the issue of abortion, though in
different capacities and roles but are equally concerned about women getting safe abortion facilities. Your
identities, unless wanted by you, will not be revealed ever at any point during or after the research.
We have come up with some research material based on the earlier study. We would be most happy to make
it available for you. Please feel free to get more information from us about our institution and our work. Ms.
Anjali Ganpule, Ms. Madhuri Sumant, Ms. Mugdha Lele, Ms Hemlata Pisal and myself form the research
team on this project. One of us will be there for conducting interview. I am sure you will have lot many queries
to be answered by us. We will be happy to do it.
Thanking you for sparing your precious time for us. With regards,
Sincerely
(Dr Sunita Bandewar)
Project-in-charge, REAP, CEHAT.
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