Unsafe abortion, "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" [1
], is a neglected women's health issue in India and in many developing nations. Of the 6.4 million abortions performed in India in 2002 and 2003, 3.6 million (56%) were unsafe [2
]. Worldwide, approximately 42 million pregnancies each year end in abortion [3
], with 21.6 million of these abortions taking place under unsafe conditions [4
]. Nearly all unsafe abortions (95-97%) occur in developing countries [4
Unsafe abortion is associated with maternal mortality. In India, 12,000 deaths each year result from abortion-related complications [6
]. Estimates for the contribution of unsafe abortions to maternal death in India vary from 9-20% [2
]. Globally, it is estimated that unsafe abortions result in 47,000 deaths annually, and approximately 13% of all maternal deaths worldwide are attributable to unsafe abortion [4
]. Leading causes of death include hemorrhage, infection, and poisoning from substances used to induce abortion [15
Unsafe abortions are also strongly associated with maternal morbidity from complications such as hemorrhage, sepsis, peritonitis, and trauma to the cervix, vagina, uterus, and abdominal organs [15
]. Morbidity from unsafe abortion is considered a serious problem in India [2
]. Globally, high proportions of women (20-50%) who have unsafe abortions are hospitalized for complications [17
]. Common long-term health problems caused by unsafe abortion include chronic pain, pelvic inflammatory disease, tubal blockage and secondary infertility [15
]. Other potential consequences include an increased chance of ectopic pregnancy, spontaneous abortion, or premature delivery in subsequent pregnancies [15
Almost all abortion-related deaths are preventable when performed by a qualified provider using correct techniques under sanitary conditions [5
]. Recognizing the preventable nature of most maternal mortality and morbidity related to unsafe abortion [15
], the Indian parliament passed the Medical Termination of Pregnancy (MTP) Act in 1971 [21
]. This relatively liberal law permits a woman to seek an abortion to save her life, preserve her physical and mental health, for economic or social reasons, and in cases of rape or incest, fetal impairment, or when pregnancy results from contraceptive failure [12
]. Subsequent amendments in 2002 and 2003 have aimed to expand safe services by devolving abortion service regulation to the district level, changing physical requirements for facilities providing first trimester abortions, and allowing medical abortion at facilities not approved for surgical abortion [21
In addition to these legal and policy interventions, a number of interventions to increase the availability of safe abortion services have been implemented in India. For example, Ipas, a global non-profit reproductive health organization focused on safe abortion and women's reproductive rights, has helped establish 84 public sector and 5 private sector comprehensive abortion care training centers in India. More than 4209 providers, 2656 with a Bachelor of Medicine, Bachelor of Science (MBBS) degree and 1553 providers who are specialists in obstetrics and gynecology, have been trained, and three-fourths of providers trained by Ipas currently provide abortion services. Along with the Government of India (GoI), many non-governmental organizations (NGOs) like Janai, Pathfinder, Family Planning Association of India, and Parivar Seva Sanstha are also intervening to improve access to safe abortion services.
Unfortunately, these policy and service delivery interventions have not led to a significant reduction in unsafe abortion or related maternal mortality and morbidity in India [22
], primarily because of limited access to and utilization of safe abortion services. While three-fourths of the Indian population live in rural areas, abortion services are rarely available at rural health facilities because trained doctors are not available to staff them [23
]. Available safe abortion services are underutilized due to numerous individual and community-level factors, such as lack of awareness of the legality of abortion, limited understanding on the implications of unsafe abortion and lack of information on availability of safe providers and methods [25
One way to address the gap between service availability and utilization is through behavior change communication (BCC) interventions. The theory behind BCC interventions is that by using communication channels to promote healthful behaviors and by creating a supportive environment, individuals will be able to act on these health-promoting behaviors [26
]. A key goal of behavior change programs is to increase individuals' self-efficacy to engage in these health-promoting behaviors [27
]. Though BCC interventions have successfully been used in India to increase knowledge of contraceptive use, immunization and HIV/AIDS [28
], they have rarely been used to increase awareness of abortion issues. In rural Maharashtra, an intervention was developed to increase access to safe abortion services using both facility-based and community-based approaches [30
]. This intervention included a BCC component, and though a formal impact evaluation was not conducted, evidence suggests that this type of community-based education campaign can be effective in increasing demand for abortion services in India [30
The Behavioral Model of Health Services Use [31
] is a useful conceptual model for understanding how interventions such as BCC campaigns can increase access to safe abortion services. Andersen delineates between potential access, which he defines as having enabling resources, and realized access, defined as use of health services [32
]. The focus of this paper is on potential access since the goal of BCC interventions is to improve access to services by creating an enabling environment. Andersen argues that enabling resources are a measure of potential access because when they are present, the likelihood of service utilization increases [32
]. Enabling resources include both community and personal resources such as trained health personnel and facilities nearby, knowledge of how to obtain the available services, financial resources to obtain services and social support for care-seeking [32
]. BCC interventions aim to build these enabling resources by increasing knowledge and creating an environment in which women are supported in using available safe abortion services when they are needed.
In order to design effective interventions, public health professionals need to understand what enabling resources are in place from the perspective of women of reproductive age. This includes an understanding of the characteristics of women who use or seek access to existing services [34
], their needs [34
], and an understanding of the dynamics of their decision-making processes related to unwanted pregnancy and abortion [35
]. The purpose of this study is to develop an evidence base for understanding accessibility of safe abortion services in Bihar and Jharkhand, India from the perspective of rural Indian women. This woman-centered perspective will be ascertained through the following research questions:
1. What are the socio-demographic, economic, and reproductive characteristics of women in four selected districts in Bihar and Jharkhand?
2. To what extent are women in Bihar and Jharkhand exposed to mass media and other sources of information? What sources of information do they typically rely on for different types of issues?
3. What abortion-related knowledge, perceptions and practices characterize these women?