Unsafe abortions are killing a woman every two hours in this country, according to estimates and calculations correlating data on maternal mortality ratio (MMR) and Sample Registration System (SRS) data by Ipas, India, an international NGO working on increasing access to safe abortion services. The last nationwide MMR data giving details of causes of maternal deaths was in SRS 2001-03, said advisor, policy for Ipas India, Medha Gandhi.

While India’s MMR has declined from 254 per 1,00,000 live births in 2004-06 to 212 in 2007-09, no recent incidence study provides data after 2002-03 on unsafe abortions, said Ms. Gandhi. As per SRS 2001-03, abortion-related deaths contribute to 8 per cent of (around 4,600 deaths annually) of all maternal deaths in India. Ipas’ calculations, using national census and SRS data, indicates that one woman dies of abortion-related causes every two hours.

One of the major reasons is that the Centre is yet to implement the recommendations for amendments to the Medical Termination of Pregnancy (MTP) Act as discussed by an expert group it had constituted in 2010. The MTP Act, 1971, enabled women to undergo abortions with specific conditions. It was amended in 2003 to facilitate better implementation and increase access for women, especially in the private health sector.

However, over 40 years after the implementation of a liberal MTP Act, unsafe abortions continue to outnumber safe and legal abortions in India, said Ipas. To correct this, the Ministry of Health and Family Welfare had appointed the expert group to examine the MTP Act and amend it to enable increased access to safe abortion services.

Vinoj Manning, country director, Ipas, India, said abortion deaths are under-reported. A Lancet paper in 2007 said there were 6.4 million abortions, of which 3.6 million or 56 per cent were unsafe. Ipas has calculated based on the latest population and crude birth rates (CBR) which peg the number of induced abortion at 5,007,932, Ms. Gandhi said. The total number of abortions may have reduced due to higher use of contraception, she added.

Three years after the expert group was formed, no decision has been taken to amend the MTP Act based on its recommendations. It is feared that expanding the base of providers for abortion will lead to more sex-selective abortions. However, Ipas said 80-90 per cent abortions in the country take place in the first trimester and sex determination takes place in the second trimester. Women also delay abortion till the second trimester for reasons other than sex selection.

In the absence of safe legal options, women opt for backroom procedures which can be fatal. The proposed amendments to the MTP Act are aimed at increasing the availability of safe and legal abortion services. This was vital, as morbidity from unsafe abortions continues to remain high, Mr. Manning said. While there is no current nationwide data on this, figures from a 2003 national facility survey are illustrative. In terms of accessibility of safe abortion services in the public health system where a MTP is available, only 73 per cent district hospitals in major States had this facility. In Bihar, it was only 35 per cent district hospitals and Uttar Pradesh 48.5, the lowest in the country. On the percentage of health facilities with at least one doctor who received training during the last three years, the situation was grim with only 14.6 per cent in primary health centres being trained.

Collating the research findings on who seeks abortions in India, Ipas referred to a qualitative study in six States and a community-based survey in Maharashtra and Tamil Nadu in 2003-04. The Abortion Assessment Project in its study found that most abortion seekers are married women who want to limit their families or space their children. Though awareness of family planning was high, women were not always able to use it because of cost, non-availability or lack of permission from husbands apart from fear of side effects. Additionally, women were hesitant to visit public hospitals because of long waiting times or unsympathetic attitude of staff or because doctors insisted on the husband’s signature.

To expand the base of legal providers, the expert group had suggested amendments for mid-level providers. In countries like Bangladesh for instance, field workers are trained to conduct abortions. “We haven’t taken a quantum leap for abortion and the law has not kept pace with technical options. Abortion is still stigmatised,” Mr. Manning pointed out.

The group has recommended increasing the base of legal MTP providers by including medical practitioners with a Bachelor’s degree in Unani, Ayurveda or Homeopathy. Nurses with a three and half year’s degree and registered with the Nursing Council of India, could also be included in the base of legal providers. Since the training required to provide only medical methods of abortion is significantly less than surgical abortions, it has been recommended to distinguish between the two trainings.