In India, induced abortion is legal up to 20 weeks’ gestation, yet there are no state-level representative data on the health care services available to women seeking an abortion or care for complications following an abortion. This fact sheet examines the provision of these vital services in Assam.
Overview of the study
Between March and August of 2015, a team of researchers surveyed a sample of health facilities in six Indian states (Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh) as part of a study to generate high-quality data on the availability of induced abortion and postabortion care and the incidence of abortion and unintended pregnancy in India.
The study team randomly selected 70% of each state’s districts, and identified and sampled public, private and NGO facilities within these districts. In the public sector, district hospitals, subdivisional hospitals and community health centers (CHCs) were sampled using lists obtained from the Ministry of Health and Family Welfare (MOHFW). A proportion of the primary health centers (PHCs) that are administratively linked to the sampled CHCs were also sampled. In addition, the study team listed and sampled public facilities not listed by MOHFW (urban public facilities), as well as private and NGO facilities (hospitals, medical colleges, maternity and nursing homes, and clinics) that offer induced abortion or postabortion services: In rural areas, facilities located in the catchment areas of a subsample of CHCs were listed, and in urban areas, facilities located within a sample of urban wards were listed. At each sampled facility, trained investigators conducted an in-person interview using a structured questionnaire with a senior professional knowledgeable about the provision of abortion-related services (typically the director or head of the facility or of the department responsible for obstetrics and gynecology). The study and its protocols were approved by the Institutional Review Boards of the three institutions conducting the study.
In Assam, 19 of 27 districts were sampled for inclusion in the study. A total of 145 public facilities, including 73 that reported providing any abortion-related service, and 32 private facilities providing abortion-related services completed the survey. These facilities represent all 1,236 public facilities operating in Assam (including 359 that provide abortion-related services), as well as the 229 private facilities offering abortion or postabortion care in the state; no NGO facilities were eligible for inclusion. The analysis differentiates facilities according to ownership (public or private) and type (grouped into categories that generally correspond to facility capacity*). Detailed distributions in tables and figures do not always sum to 100 because of rounding.
Public and private facilities offering abortion-related services
- An estimated 588 facilities in Assam provide abortion-related services (induced abortion, postabortion care or both; Table 1). Of these, 359 are public and 229 are private.
- Primary health centers (PHCs) make up the largest share of all facilities offering abortion-related services, accounting for 34%, followed by private maternity and nursing homes, which account for 23% (Figure 1).
- Among facilities offering any such services, 66% offer both abortion and postabortion care, 30% offer only postabortion care and 4% offer only abortion.
- Nearly all public hospitals that offer any abortion-related services (96%) provide both types of care, as do large majorities of private maternity and nursing homes (83%), community health centers (CHCs; 82%) and private hospitals (69%).
- In contrast, among PHCs that offer any abortion-related services, three-fifths (58%) provide only postabortion care.
- Fifty-five percent of all facilities offering induced abortion or postabortion care are located in urban areas. Nearly seven in 10 of these urban facilities (71%) are privately owned.
- In rural areas, on the other hand, 100% of facilities offering abortion-related services are public.
- Among private facilities offering induced abortion, 66% report they are certified under the Medical Termination of Pregnancy Act to provide this service.
Availability of abortion-related services in the public sector
- Twenty-nine percent of all public facilities in Assam offer some type of abortion-related services (Figure 2). Eighteen percent offer both induced abortion and postabortion care (including 2% that offer only abortion), while 11% offer only postabortion care. Seventy-one percent of public facilities offer neither service.
- Public provision of any abortion-related services varies by facility type: Nearly all hospitals (97%) and most CHCs (61%) offer induced abortion, postabortion care or both, whereas only 20% of PHCs do so.
- Eighteen percent of public facilities in Assam provide induced abortion—95% of hospitals, 50% of CHCs and 8% of PHCs—and almost all of these facilities also offer postabortion care (93% of hospitals, 50% of CHCs and 6% of PHCs offer both).
- Overall, 27% of public facilities provide postabortion care, and some offer only postabortion care: 2% of hospitals, 11% of CHCs and 11% of PHCs.
- Viewed another way, the data show that a large majority (82%) of public facilities—5% of hospitals, 50% of CHCs and 92% of PHCs—do not offer abortion.
Reasons for not offering abortion
- Among facilities whose abortion-related services are restricted to postabortion care, the reasons reported for not offering induced abortion vary according to whether facilities are public or private.
- Public facilities offering only postabortion care most commonly cite lack of trained staff (67%) and lack of equipment or supplies (32%) as reasons for not offering abortion.
- In contrast, private facilities offering only postabortion care report lack of certification (50%) and religious or social reasons (50%) as grounds for not offering the procedure.
- Among all public facilities not offering abortion—including those that offer no abortion-related services, as well as those offering only postabortion care—the most prevalent reasons reported for not doing so are the same as those reported by public facilities offering only postabortion care: lack of trained staff (79%) and lack of equipment or supplies (52%).
- Reasons vary by type of public facility. Among all public hospitals not offering abortion, lack of trained staff is the main reason cited (65%), followed by religious or social reasons (35%). CHCs and PHCs cite lack of trained staff (79–86%), equipment or supplies (50–53%) and space (7–23%) as the main reasons for not providing abortions.
Types of abortion procedures offered
- Among the public and private facilities that provide induced abortion, 81% offer both medical methods of abortion (MMA)† and surgical methods, 3% offer only MMA and 16% offer only surgical methods.
- Facilities offering abortion report using the following specific methods: MMA using combipacks containing misoprostol and mifepristone (offered by 80%); MMA using only misoprostol (53%); manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA) procedures (89%); and dilatation and evacuation or dilatation and curettage (95%).
- A higher proportion of private facilities (88%) than of public facilities (76%) that offer abortion use both MMA and surgical methods.
- The majority of facilities that provide abortion offer both; provision is limited to MMA at some PHCs (13%) but at no other type of facility.
Vacuum aspiration equipment and training
- In Assam, nearly all facilities that offer abortion using MVA or EVA (96–98%) have functional equipment available at least some of the time and at least one provider trained in the procedure.
- A somewhat lower proportion (90–94%) of facilities offering these procedures have a trained provider and have functional equipment available all or most of the time when it is needed. This proportion is lowest among PHCs offering MVA (50%).
Gestation at which abortion services are offered
- In India, induced abortion is legal up to 20 weeks’ gestation; for abortions performed between 12 and 20 weeks, authorization by two doctors is required. Pregnancies beyond 20 weeks may be terminated only to save a woman’s life.
- However, the majority of facilities providing induced abortion in Assam—54%—offer procedures during the first trimester only (at or before 12 weeks); 11% of facilities restrict provision to the first seven weeks of pregnancy. All private clinics, 64% of CHCs and 75% of PHCs that offer abortion do so only in the first trimester.
- Among the 184 private facilities offering abortion, 54% provide services during the second trimester of pregnancy (Figure 3). Among the 226 public facilities offering such care, 40% provide second-trimester procedures.
- Although abortion provision beyond the first trimester is relatively inaccessible throughout the state, the proportion of facilities offering second-trimester procedures is particularly low in rural areas (27%), compared with urban areas (56%).
Consent for abortion procedures
- Providers are required to obtain a woman’s consent before performing an abortion, and the vast majority of facilities (94%) report this is commonly done.
- Consent is not legally required from anyone other than the woman obtaining the procedure, unless she has a mental illness or is a minor. However, many facilities (85%) routinely seek the consent of the woman’s husband or partner. Ten percent report commonly asking for consent from the parents of unmarried women.
Turning away abortion seekers
- Overall, an estimated 6% of women seeking induced abortion from facilities offering abortion in Assam were turned away.
- Two-thirds (69%) of facilities offering induced abortion report having turned away one or more women seeking an abortion in the last year. Among these facilities, the most common group of reasons for turning away abortion seekers was related to capacity to provide needed abortion services—including that the pregnancy was too far along for the facility or that the facility lacked a trained provider (74% of public facilities and 34% of private facilities that turned away any abortion seekers reported one or more of these reasons).
- Facilities also report turning away some women who could have been served. Slightly more than half of facilities that turned away women seeking abortion did so for one or more of the following reasons: the woman was “too young,” had no children or was unmarried. A small proportion of facilities that turned away abortion seekers (12% of public and 3% of private facilities) did so because the woman’s husband or partner had not consented to the procedure.
Accessibility of postabortion care
- Eighty-two percent of facilities providing postabortion care services (including 100% of public and private hospitals) offer care 24 hours a day, seven days a week.
- Availability of around-the-clock postabortion services is greater among facilities providing this care in urban areas (91%) than among those in rural areas (70%). In rural areas, care is available 24-7 at 100% of public hospitals and 83% of CHCs, but at only 63% of PHCs.
- Fifty-six percent of facilities offering postabortion care services provide both outpatient and inpatient care. However, 35% of public facilities and 29% of private facilities offer only outpatient services, indicating that they may not have the capacity to treat severe complications.
- The majority of PHCs (53%) and all private clinics (100%) offer only outpatient services.
Contraceptive care offered
- All facilities in Assam that offer abortion-related care report providing information about family planning to the vast majority of women seeking induced abortion or postabortion care services.
- Although most of these facilities cover the correct use of methods (67%), fewer provide information on what methods are available (43%), the advantages and disadvantages of different methods (31%) or what to do in case of method failure or incorrect use (27%).
- Nearly all facilities that offer abortion or postabortion care also provide contraceptives. However, facilities report that, on average, only about half of women seeking abortion-related services adopt a contraceptive method. Contraceptive uptake is roughly comparable across most types of facilities (46–70%).
*Public facilities are grouped into hospitals (rural, district or civil, subdivisional, municipal, tertiary and railway hospitals, and public medical colleges), CHCs (first referral units and non–first referral facilities) and PHCs (those that are and are not open 24-7, as well as block PHCs). Private facilities are grouped into hospitals (multispecialty and specialized hospitals and private medical colleges), maternity and nursing homes, and clinics.
†MMA is also referred to as medication abortion outside of India.
The data in this fact sheet come from An Assessment of the Incidence of Unintended Pregnancy and Induced Abortion in India, a study currently being conducted by the International Institute for Population Sciences (IIPS), Mumbai; the Population Council, New Delhi; and the Guttmacher Institute, New York. The study benefited from consultations with a range of stakeholders, from research review by a Technical Advisory Committee and from the guidance of a Steering Committee, chaired by the Additional Secretary and Mission Director (NHM), Ministry of Health & Family Welfare, Government of India.
The study on which this fact sheet is based was made possible by grants from the Government of UK Department for International Development (until 2015), the David and Lucile Packard Foundation and the John D. and Catherine T. MacArthur Foundation. The views expressed do not necessarily reflect the official policies of the donors.