Provision of Abortion and Postabortion Services in Bihar, 2015
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 Bihar.
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 Bihar, 27 of 38 districts were sampled for inclusion in the study. A total of 320 public facililties (including 136 that reported providing any abortion-related service) completed the survey, as did 242 private facilities and 15 NGO facilities that provide abortion-related services. These represent all 2,127 public facilities operating in Bihar (including 629 that provide abortion-related services), as well as the 2,205 private and NGO facilities offering abortion or postabortion care in the state. The analysis differentiates facilities according to ownership (public or private) and type (grouped into categories that generally correspond to facility capacity*). Because NGOs make up a very small proportion of our sample, they were combined with private facilities in this analysis. 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 2,834 facilities in Bihar provide abortion-related services (abortion, postabortion care or both; Table 1). Of these, 629 are public and 2,205 are private (including NGOs).
- Private maternity and nursing homes make up the largest share of all facilities offering abortion-related services, accounting for 50%, followed by private clinics, which account for 22% (Figure 1).
- Among facilities offering any such services, 34% offer only postabortion care, 59% offer both abortion and postabortion care, and 6% offer only abortion.
- About seven in 10 public hospitals (71%), private hospitals (76%) and private maternity or nursing homes (73%) that offer any abortion-related services provide both types.
- In contrast, among PHCs that offer any abortion-related services, 79% provide only postabortion care.
- The majority (69%) of facilities offering abortion or postabortion care are located in urban areas. More than eight in 10 of these urban facilities (87%) are privately owned.
- In rural areas, on the other hand, the facilities that offer abortion-related services are evenly split between the public and private sector.
- Among private facilities offering abortion, only 22% report that they are certified under the Medical Termination of Pregnancy Act to provide this service.
Availability of abortion-related services in the public sector
- Thirty percent (30%) of all public facilities in Bihar offer any type of abortion-related services (Figure 2). Eleven percent offer both induced abortion and postabortion care or only abortion (1%), while 19% offer only postabortion care. Seventy percent of public facilities offer neither service.
- Public provision of any abortion-related services varies by facility type: Seventy-seven percent of hospitals and 59% of community health centers (CHCs) offer abortion, postabortion care or both, while only 23% of PHCs do so (and nearly all of these offer only postabortion care).
- Eleven percent of public facilities in Bihar provide induced abortion—56% of hospitals, 33% of CHCs and 5% of PHCs—and almost all of these facilities also offer postabortion care (55% of hospitals, 33% of CHCs and 4% of PHCs).
- Overall, 28% of public facilities provide postabortion care, and many offer only postabortion care: 21% of hospitals, 26% of CHCs and 18% of PHCs.
- Viewed another way, the data show that a large majority (89%) of public facilities—44% of hospitals, 67% of CHCs and 95% 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 commonly cite lack of trained staff (81%) and lack of equipment or supplies (63%) as reasons for not offering induced abortion.
- In contrast, private facilities offering only postabortion care most commonly report lack of certification (56%), religious or social reasons (42%) or lack of equipment or supplies (32%) as grounds for not offering the procedure. Nineteen percent report lack of trained staff.
- 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 similar to those reported by public facilities offering only postabortion care: lack of trained staff (89%) and lack of equipment or supplies (77%).
- In Bihar, reasons for not offering abortion vary little by type of public facility.
Types of abortion procedures offered
- Among the public and private facilities that provide induced abortion, 75% offer both medical methods of abortion (MMA)† and surgical methods, 11% offer only MMA and 14% offer only surgical methods.
- Facilities offering abortion report using the following specific methods: MMA using combipacks containing misoprostol and mifepristone (offered by 86%); MMA using only misoprostol (77%); manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA) procedures (72%); dilatation and evacuation or dilatation and curettage (85%).
- A higher proportion of private facilities (78%) than of public facilities (52%) that offer abortion use both MMA and surgical methods.
- A sizable share of lower-level facilities that offer abortion report that provision is limited to MMA: 11% of CHCs, 39% of PHCs and 31% of private clinics.
Vacuum aspiration equipment and training
- In Bihar, nearly all facilities that offer abortion using MVA or EVA (96–100%) have functional equipment available at least some of the time and at least one provider trained in the procedure.
- A slightly lower proportion (94–96%) of facilities offering these procedures have a trained provider and have functional equipment available all or most of the time when it is needed.
Gestation at which abortion services are offered
- In India, 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 large majority of facilities providing abortion services in Bihar—73%—offer procedures during the first trimester only (at or before 12 weeks); 17% of facilities restrict provision to the first seven weeks of pregnancy.
- Among the 1,637 private facilities offering abortion, 28% provide services during the second trimester of pregnancy (Figure 3). Among the 227 public facilities offering such care, 24% provide second-trimester procedures.
- Abortion provision beyond the first trimester is relatively inaccessible throughout the state, and the proportion of facilities offering second-trimester procedures is similar in urban areas (26%) and rural areas (32%).
Consent for abortion procedures
- Providers are required to obtain a woman’s consent before performing an abortion, and the vast majority of facilities (82%) report this is commonly done. However, a lower proportion of public facilities (62%) than private facilities (85%) report doing so.
- 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 (77%) routinely seek the consent of the woman’s husband or partner. Twenty-six percent report commonly asking for consent from married women’s in-laws, and 44% report commonly asking the parents of unmarried women.
Turning away abortion seekers
- Overall, an estimated 24% of women seeking induced abortion from facilities offering abortion in Bihar were turned away—23% of women seeking abortion from private facilities and 38% seeking abortion from public facilities.
- Eighty-seven percent 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 or the requested method (79% of 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. Nearly one-third 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 (18%) did so because the woman’s husband or partner had not consented to the procedure.
Accessibility of postabortion care
- Seventy-three percent of facilities providing postabortion care services (including 72–77% 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 (81%) than among those in rural areas (56%). In rural areas, care is available 24-7 at 100% of public hospitals and 83% of CHCs, but at only 36% of PHCs. Among rural private facilities, it is available 24-7 in 68% of facilities, and this proportion varies little by facility type.
- Eighty-four percent of facilities offering postabortion care services provide both outpatient and inpatient care. However, 40% of public facilities and 7% of private facilities offer only outpatient services, indicating that they may not have the capacity to treat severe complications. This includes 11% of public hospitals and 16% of CHCs.
- More than half of PHCs (54%) offer only outpatient services.
Contraceptive care offered
- Nearly all facilities in Bihar 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 advantages and disadvantages of different methods (77%) and the correct use of methods (52%), only a minority provide information on what methods are available (39%) or on what to do in case of method failure or incorrect use (16%). These proportions are similar at public and private facilities.
- 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 ranges from 44% among clients at PHCs to 61% among clients at public hospitals.
- Thirteen percent of facilities that offer any abortion-related services report that at least some women are required to adopt contraception as a condition of receiving an abortion. This proportion does not differ between public and private facilities.
*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.
This fact sheet is published as part of the study, An Assessment of the Incidence of Unintended Pregnancy and Induced Abortion in India, 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, the John D. and Catherine T. MacArthur Foundation and the Ford Foundation. The views expressed do not necessarily reflect the official policies of the donors.