Report & Recommendations
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Advances in Methods of Emergency Contraception
Socio-demographic problems of unsafe abortion
–Dr MC Kapilashrami, NIHFW

Abortion is the termination of pregnancy at any time before the foetus has attained the stage of viability. This has been fixed administratively at 28 weeks, which corresponds to a foetal weight of 1000 gms. With expert neonatal care, this limit has been brought down to 20 weeks of pregnancy, corresponding to foetal weight of 500 grams in developed countries.

Abortions may be spontaneous or induced. Induced abortions are deliberately carried out and these may be legal or illegal. Spontaneous abortions can be further categorized into threatened, inevitable, incomplete, complete, missed and septic abortions.

Unsafe abortions are those which are performed by untrained persons and/or in improperly-equipped institutions, and are more likely to result in maternal morbidity and/or mortality. Spontaneous abortion if not properly managed can also be unsafe and induced abortions carried out illegally are generally unsafe. Occasionally, an illegal abortion may not be unsafe when carried out by a qualified person in a wellequipped place (though not certified – safe illegal abortions).

Various studies show the proportion of abortions ranges from 9-15% of total pregnancies. In some countries (e.g. Hungary), legal abortions exceed live births. The actual incidence of abortions worldwide is not known but estimates range from 40-60 million a year of which at least half are unsafe. Nearly 40-50 per 1000 women of reproductive age have abortions annually with an abortion ratio of 260-450 per 1000 live births.

In India, it is estimated that about 6 million abortions take place every year, of which 2 million arespontaneous and 4 million are induced. Of the induced abortions, nearly 5-6 lakhs are legal and the rest are estimated to be illegal abortions.

Spontaneous abortion rates are influenced by age at menarche and smoking rate. Higher gravidity / parity of woman and history of previous abortions, genetic factors, maternal infections, uterine abnormalities or hormonal defects lead to most spontaneous abortions.

In India, abortions were illegal and amounted to homicide till 1971 (as per provisions under IPC 1860 and CPC 1898). MTP Act was passed in 1971 and came into force with effect from 1st April, 1972. Under the MTP Act, the following are strictly specified:

• Maternal/ Fetal conditions under which MTP can be done
• Place where it can be done
• Persons who can do it

MTP was introduced in India as a maternal health measure and NOT as a birth control measure. Unsafe abortions account for nearly 200,000 maternal deaths in developing countries annually. Treating women who had illegal abortions drain health systems and the women face long term morbidity and social disability.

Abortion will continue to exist as long as women face unwanted pregnancies, and unwanted pregnancies will continue to occur until women gain the power to determine their sex behaviour. Though abortion is legalized, illegal abortions abound. It is estimated that 90% of India’s 6 million annual abortions are carried out in unhygienic conditions and hence are unsafe.

Women who seek abortion at unauthorized facilities or from unskilled persons put not only their health but also their lives at risk. Although unsafe abortion is a public health problem at all ages, it is particularly so among young women. These young women often havea poor access to family planning and are less likely than older women to have the contacts and money to obtain a safe abortion. Abortion-related morbidity and mortality are much higher in the second trimester of pregnancy. Women abort later as they have neglected their healthcare.

As with all other data on illegal abortions, information on the social and demographic characteristics of women resorting to illegal abortions is fragmentary and biased. A variety of factors, including reproductive behaviour, accessibility and use of effective contraception, socio-economic conditions and cultural mores, influence the behaviour of women seeking illegal abortions.

The profile of safe abortion-seekers and unsafe abortion seekers is different.

Table 1.2.1
Profile of abortion Seekers

Safe Abortion Profile Unsafe Abortion Profile
• women in age group 20 and early 30
• married
• usually multiparous with 2 or 3 children
• coming from all socio economic strata
• not much of a rural urban bias
• in places where services are readily accessible
• teenage girls or women in late 30 and early 40
• many times unmarried or widowed
• usually of lower socio economic status
• illiterate and of rural origin
• timing of abortions is late-first or second trimester
• mostly in un-recognised places

The profile of people providing abortion has, perhaps, undergone some change during the last 50 years. Earlier, the providers of abortion used to be Dais, barber-women or traditional-healers and the methods adopted used to be pastes, herbal products, sticks, etc. Currently, however, some studies have shown that, in a fairly sizeable proportion of cases, abortions are being provided by healthcare professionals-both of modern system of medicine as well as ISM and Homeopathy but majority without the requisite qualifications, skill and experience. The method used is surgical dilatation and evacuation of the uterus.

Morbidity and mortality from illegal unsafe abortions vary according to conditions under which the abortion is erformed, the procedure adopted, the skill of the person performing it, the stage of gestation and age, health and parity of the woman. Where abortions are legal and statistics are accurate, the mortality ratio ranges form 1 to 3.5 per 100,000 abortions in the developed countries. In India, the mortality is reported to be 7.8 per 1000 random abortions, most of which are illegal. Studies indicate that risk of death is 7 times higher for women who wait until the second trimester
for termination of pregnancy.

Unfortunately, data on morbidity are very limited and fragmentary. Illegal abortions are a frequent cause of severe short-term complications and long-term sequelae. The most common early complications are excessive blood loss, pelvic infection, uterine perforation, cervical injury, thromboembolism, anaesthetic complications and shock. The late sequelae include infertility, ectopic pregnancy, increased risk of spontaneous abortion etc.

There is an urgent need to correct anomaly of safe versus illegal abortions. Some of the steps are:

• awareness of availability of legal and safe abortion facility as a maternal health measure.
• increase access to and the choice of methods available for safe abortion services.
• ensure appropriate referral facilities.

There is a challenge to provide safe abortion services to all those in need of abortion and to fully meet the unmet needs for contraception so as to reduce the need for abortion. Providing appropriate contraceptive care at the time of MTP will prevent these women from the risk of yet another unwanted pregnancy and induced abortion. All these will go a long way in achieving substantial reduction in morbidity and mortality associated with induced abortions.

An unsafe abortion is "a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both" (WHO Definition).

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Current Status of Medical Abortion | Consensus Issues & Recommendations
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