Abortions are a major cause of maternal morbidity and mortality in India. Estimated number of abortions a woman will have throughout her reproductive years is 1 to 2.6. Estimated annual number of induced abortions varies nationwide from 0.6 (GOI, 1991-92) to 6.7 million (Chhabra and Nuna, 1994).

The facilities for safe abortions fall short of the need of abortion as reported MTPs are about 600,000 per year but total induced abortions are estimated at between 1.9 and 6.7 million. Under-reporting by government and private institutions is a major reason. In India, certified facilities for MTP have increased from 1877 to 9271 between 1972 and 1993-94. States with the highest number of MTP facilities per 100,000 population are Maharashtra, Kerela, Gujarat, Haryana and Punjab. There is a mismatch between availability of government-equipped facilities, MTP-certified doctors and facilities where services are available.

Regarding indirect estimates of abortions, a very high rate of induced abortions is seen in Nagaland, Bihar, Meghalaya, Arunachal Pradesh, Uttar Pradesh, Orissa, Madhya Pradesh, West Bengal, Assam and Tripura.

A variety of methods in use for MTP include D&C, Electronic Vacuum Aspiration (EVA) and Manual Vacuum Aspiration (MVA) in first trimester, extraamniotic and intraamniotic instillations and D&E in the second trimester. MTP training centers (teaching hospitals), however, prefer EVA, D&C and induction methods and only 25% doctors are trained in MVA (CORT, 1995-97). There is a large range of clandestine abortion-providers that vary in the country from doctors (including those who are uncertified ‘safe illegal providers’) to Ayurvedic practitioners, homeopaths, Auxillary Nurse Midwives (ANMs), nurses, compounders, spouses or attendants, untrained practitioners, Traditional Birth Attendants (TBAs), shopkeepers, etc.

Methods used by informal providers vary from tablets (ayurvedic preparations, papaya seeds, chloroquin tablets, high-dose progesterone and highdose estrogen and progesterone) injections (carboprost and ayurvedic preparations), surgical methods (D&C, catheters, intra-amniotic saline or glycerine) to intravaginal sticks, roots, iodine-benzoin paste, decoctions and massage, papaya and custard apple seeds etc.

Action Research and Training in Health (ARTH) is conducting a study of abortion services in Rajasthan (2002) and has mapped all health- providers in 5 rural and 1 urban block of two districts (Population 1,388,687). Out of a total 1746 providers, 78% were practising paramedics and private unqualified persons, 5% Indian System of Medicine (ISM) practitioners and 17% medical doctors. Population per provider was 4700 for doctors, 958 for other categories, which are also better dispersed within rural interiors and urban slums. Almost half (48%) of informal providers (all except medical doctors) provided abortion services as treating delayed periods. Methods employed by informal providers ere tablets in 55%, injections in 36%, and massage/herbs in 5% as compared toinvasive methods in 4%. Informal roviders seemed to prefer ‘medical methods’.

Most women who seek abortions are 20-35 years old, married with 3 or more children and wish to limit their families and seek abortion services especially in the first trimester (ICMR 1989). Second trimester abortions represent 10-40% of all abortions (ICMR 1981) and are more likely to be seen among adolescents and women seeking sex selective abortions. More than 11% second trimester abortions have been reported in Rajasthan and Uttar Pradesh, 60% in Orissa and 35% in Tamil Nadu.

Abortions among adolescents vary from 5.7% of all abortions in urban government hospital settings to 27- 30% of all abortions in some clinics (Chhabra 1988, Solapurkar and Sangam, 1985) and 59-76% of abortions among unmarried adolescents are in second trimester (Chhabra 1988; Aras, 1987). Abortions in adolescents are more likely to be performed by untrained persons in unhygienic conditions and can contribute to 20% of all abortion-related deaths among adolescents (GOI).

Safe abortion services in India remain inaccessible in rural areas despite MTP Act and Rules because facility and provider requirements are restricted and geographical distribution of facilities is skewed. Most private facilities exist in cities and most rural government facilities do not provide abortion services.

Certified facilities have low caseloads due to lack of confidentiality, high costs, difficult consent, and pressure to accept sterilization or IUD. Even at many government facilities, services are not available due to lack of trained doctors, functional equipments, anaesthetists and electricity (Barge et al, CORT 1998) and limited training capacity. There are limited MTP training facilities with merely 166 MTP training institutions in 1994. Given such a situation, where safe abortion services are not easily accessible, the problem of abortion is of great magnitude and makes a major contribution to maternal deaths.

The question arises as to how best can medical methods be used to enhance access to safe abortion in India.