Making Abortion Safe in Asia: Singularity of Focus

1
Making Abortion Safe in Asia Singularity of
Focus
Priya NandaInternational Center for Research on
Women (ICRW) APCRSH, Beijing, October 19th ,
2009
2
Abortion Scenario in Asia

• High fertility rates
• High unmet need for contraception
• High rates of unwanted pregnancies and abortions
• Unsafe abortion account for about ten percent of
  MMR
• Stringent Laws/Policies
• Inequitable coverage of service facilities
  legal providers
• Limited information and choice around RH methods
• Stigma of abortion

3
Tenets of the Rights-based Approach

• Sexual and reproductive rights, understood as
  private choices, are meaningless without
  enabling conditions and public support.
• Individual and social dimensions of reproductive
  and sexual rights can not be separated as long as
  there is gender inequity.
• Application of rights needs cognizance of womens
  and girls realities. These include lack of
  resources and information, inability to negotiate
  contraception, early marriage, unmet need,
  violence and coercion, and unfair burden of
  bearing a son.
• .

4
Introduction of MA Pills in India

• Combination of oral Mifepristone (200 mg)
  followed by Misoprostol (800 µgm)
• For gestation upto 9 weeks
• Approved in India in 2002
• MTP Act amended in 2003 to allow Medical Abortion
  (MA)
• Currently around 20 brands available
• Has transformative characteristics easier
  access, safe, easy to use, cost effective,
  non-invasive, expanded choice and offers
  confidentiality
• YET
• Access to use of MA pills limited

5
Women access a diversified provider base, both
within outside the law

• Providers accessed
• 43 Ob/Gynaecologists
• 29 Indian system of medicine i.e. BHMS/BAMS
• 14 General practitioners (MBBS)
• 8 Pharmacists
• 6 Nurses
• Rational choices Convenience/distance,
  familiarity, affordability,
• confidentiality

6
What a woman need in choice of facility/provider
I went to the doctor (MBBS ,Private) since she
was known to me, she provided good services,
explained everything and was also near to my
home. In case of any difficulty, it would be
convenient to go for follow-up visit. 28 years
old, Xth grade, rural woman with 1 son
7
Women acknowledge positive and potentially
transformative attributes of MA

• Users articulate a sense of relief on complete
  abortion
• 1/3rd decided on their own to use MA
• Reported easy availability, affordability
  privacy as key factors
• 82 had no significant side effects with use
• Some pain and bleeding within 12 hrs of taking
  drug but expected it from some pre-procedure
  counseling
• Several needed privacy due to coercion or
  violence at home

8
Confidentiality unique to method choice

• At the abortion centre I was told about two
  procedures of abortion. The doctor told me that
  the medicinal procedure was straight, simple and
  beneficial. .. no need to stay in the hospital.
  There was absolutely no confusion in my mind. I
  opted for medicinal procedure as it was readily
  available, provider was nearby, it was
  affordable,. was no need to stay in hospital.
  Besides everything would be confidential.

9

• Providers impact quality differentially
• Consent varied- mostly for self protection or
  inform women of risks rather than informed
  choice
• Varied regimen and protocol
• Not all are trained as not recognized by law
• Lack of gendered perspective provider hierarchy
• Different emphasis on follow up or PAC

10
Limited knowledge about relevant laws
guidelines

• gt50 providers not aware of stipulations under
  MTP Act
• gt50 providers unaware of guidelines for MA
• 2/3rd women unaware of MTP Act but aware of
  PCPNDT Act due to heightened attention on sex
  selection
• No information in public domain because MA is
  Schedule H drug (no OTC so no incentive to
  advertise publically)

11
Contrasting views about types of providers who
can prescribe where

• Opposition to home use Ob/Gy
• Opposition to OTC All providers
• Bias towards surgical methods Medical college
  professors
• Bias against MA for unmarried Retailers
• Concept of misuse use by unmarried women,
  taken OTC, incorrect or incomplete regimen and
  lack of follow up

12
Respondents highlight ways to maximize MAs
transformative potential

• Revise MTP Act
• Move MA into the public sector
• Diversify and potentially de-medicalize provide
  base
• Retailers to provide information, if no OTC
• Manufacturers should have ensure package inserts
• Introduce dedicated combination pack

13
Diversify Access

• Women or their partners go to chemists tell them
  about the unwanted pregnancy and ask for some
  pill .. More than half these women / their
  partners do not come with any doctors
  prescriptions. The chemists based on the
  knowledge garnered from MRs ..dispense drugs
  OTC. Senior researcher/advocate
• Non-MBBS doctors should also be allowed to
  prescribe MA after training. Also, if qualified
  nurses with midwifery training and 3 years of
  training can conduct deliveries then why not do
  MA or even MVA? There are only 22,000 members of
  FOGSI and we have a country of over 1 billion
  population. Abortion Provider Senior FOGSI
  Representative

14
Women Can Make Safe Choices

• Women clearly do not go for abortion mindlessly.
  They may be repeat aborters but that is an
  indication of their disempowerment and the fact
  that they are unable to negotiate contraception
  use. Donor, Subject Expert

15
Abortion within a Rights-based Framework

• Access Options are available, affordable and
  clients given choice
• Decision Making Decision-making process is
  voluntary, non coercive and informed.
• Services No stigma for all ages and unmarried.
  Provider knowledgeable Enhanced provider base
  with updated training.
• Experience Good counseling services and client
  provider interaction for follow up. Safe and
  complete, ideally with PAC
• Environment Laws and policies actively create
  support

16
De-medicalized Access

• A major barrier in my opinion is unawareness at
  every level, women users, chemists and
  providers. Women or their partners go to chemists
  tell them about the unwanted pregnancy and ask
  for some pill to terminate it. More than half
  these women / their partners do not come with any
  doctors prescriptions. The chemists based on
  the knowledge garnered from MRs ..dispense drugs
  OTC. Senior researcher/advocate
• I am not very comfortable with Pharmacists being
  the providers. Women can calculate their LMP and
  gestational age but a pelvic examination is
  important and if you get drugs OTC, who will do
  this? I dont agree that we should legitimize it
  just because it is happening anyway. Senior
  researcher MMA, Faculty Medical College

17

• It is a lucrative market of course. We have been
  working with hormones for long. We felt it was a
  good opportunity and there was also the concern
  that the country is burdened with the issue of
  inadequate FP and therefore unwanted pregnancies.
  There are limited abortion services available.
  Secondly we felt that this is a good product
  which has the potential to transform the way the
  condition is treated and how people handle their
  lives Senior Pharma Rep
• There are variety of way in which stakeholder
  understand, articulate and assess misuse. We do
  regular prescription surveys at random with a
  fixed no. of prescriptions from doctors. If
  20,000 anti-ulcer prescriptions are taken and
  Pantoprezol has 2000 then we estimate a 112
  ratio of actual sales. If we see a 2 lakh sale of
  Miso and estimate backwards with a 112 ratio, we
  should see at least 15,000 prescriptions. The
  reality is 28 prescriptions. We suspect that
  either the doctors stock it themselves, there are
  OTC sales or use by quacks and general
  practitioners.