Abortion has been legal in India since the early 1970s, but in five out of nine Indian states over two thirds of abortions may be unsafe. Vulnerable and disadvantaged women are particularly at risk of having an unsafe abortion, and young women (aged 15-19) have the highest risk of dying from an abortion-related complication.
A study of 1.8 million women, published in BMJ Global Health, analysed anonymous data from India’s 2010-2013 Annual Health Surveys to estimate the rates of and risk factors for unsafe abortion and abortion-related maternal mortality in nine states.
Previous research had found that women’s educational attainment, participation in the work force, social class and ethnicity, and the predominant preference for male children influenced abortion seeking, but this is the first empirical study of the combined effect of these factors on unsafe abortion.
In nine less developed states (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand and Assam), which represented 50% of the population, the overall rate of unsafe abortion was 67%. There was a large variation between states: Assam had the lowest rate (45%) whereas in Chhattisgarh a staggering 78% of abortions were unsafe.
Senior author Dr Manisha Nair, from the National Perinatal Epidemiology Unit (NPEU) in the Nuffield Department of Population Health said ‘Socioeconomic vulnerability, teenage pregnancy and inadequate access to healthcare services combine to leave large numbers of women at risk of unsafe abortion and abortion related death and constitute a major public health problem in India.’
About 70% of India’s population live in rural areas where safe abortion services are not readily available. More than half the abortion-related deaths in the study were due to a lack of access to appropriate health care. Women living in rural settings had 26% higher chance of an unsafe abortion and were more likely to die from an abortion-related cause compared to women living in urban settings.
Obstetrician and Gynaecologist (Gauhati Medical College and Hospital, Assam) and co-author, Dr Saswati Sanyal Choudhury said, ‘We manage several women in our hospital who come with complications related to unsafe abortion, often very late. It is important to prevent unsafe abortions by ensuring adequate access to family planning and early safe abortion services in the community.’
While there was an increased prevalence of abortion among educated women, the risks of unsafe abortion and of death related to abortion, were higher among those who were illiterate or uneducated. Women with no education were 48% more likely to have an unsafe abortion compared to women with higher education.
Poverty was also a major risk factor with women in the lowest household asset index quintile having 45% higher chance of an unsafe abortion than women in the highest quintile. Women in the Schedule caste and Schedule tribe social groups (historically disadvantaged people) were more likely to have an unsafe abortion than those in other social groups.
Although female selective abortion (FSA) is illegal in the country, the practice is still prevalent. The study found that women with no male children were more likely to have an unsafe abortion compared with women who had at least one male child. This is consistent with FSA being sought from unregistered and unqualified abortion providers.
The study found that 58,266 of the 89,447 abortions among women aged 15 to 58, in the nine states were unsafe. Abortions were classified as unsafe if they were not performed (if induced) or completed (if spontaneous) in a health facility or by a skilled birth attendant or were carried out at 20 weeks’ gestation or beyond.
Manisha Nair said ‘Unsafe abortion is a preventable cause of maternal mortality. There is an urgent need to further investigate the barriers to safe abortion in India and ensure adequate care for management of post-abortion complications particularly in disadvantaged and rural areas.’