The reality of unsafe abortion in a rural community in South India

Examining the rural-urban divide in predisposing, enabling, and need factors of unsafe abortion in India using Andersen's behavioral model

BACKGROUND

The prevalence of unsafe abortions significantly varies with geography; therefore, more research is needed to understand the rural-urban differences in unsafe abortion practices in India. The present study aims to explore the rural-urban differences in predisposing, enabling, and need factors of unsafe abortion in India.

METHODS

The present study used the fourth round of the National Family Health Survey (2015-16) and included the women aged 15-49 who terminated pregnancies by induced abortion during the 5 years prior to the survey (N = 9113) as the study sample. Descriptive statistics, bivariate chi-square significance test and multivariate logistic regression model were used to accomplish the study objectives.

RESULTS

The findings revealed that almost one-third of pregnancies were terminated through unsafe measures with sharp rural-urban contrast. The likelihood of unsafe abortions increases with decreasing women's age and spousal level of education. Younger women in urban settings were more vulnerable to unsafe abortion practices. In rural settings, women with an uneducated spouse are more likely to have unsafe abortions (OR: 1.92). Poor households were more likely to undergo unsafe abortions, which were more common in rural settings (OR: 1.26). The unmet need for family planning was revealed to be a significant need factor for unsafe abortion, particularly in rural settings.

CONCLUSION

Although abortion is legal, India's high estimated frequency of unsafe abortions reveals a serious public health issue. Due to socio-economic vulnerability, unmet family planning needs, and a lack of awareness, significant numbers of women still practice unsafe abortions in India.

Running an obstacle-course: a qualitative study of women's experiences with abortion-seeking in Tamil Nadu, India

Irrespective of the legal status of abortion, access to abortion services for women is fraught with numerous challenges across the world. A recent study in India found that most women who had an abortion sought care outside an authorised facility or from a less qualified provider. An analysis of women’s experiences in seeking abortion services would provide a better understanding of the underlying reasons. This paper is based on a qualitative study of the experiences of 16 married women from rural Tamil Nadu, India. The in-depth interviews focused on their pregnancy and childbirth experiences and access to abortion services. The study highlights the obstacle course that women seeking to terminate an unwanted pregnancy have to traverse. Many women were not aware of the legal status of abortion, and frontline workers discouraged them and gave misleading information. The pathways to seeking an abortion were more complex for women from marginalised communities. Providers were judgemental and used delaying tactics or denied abortion services. For the less privileged women, abortion services from government health facilities were conditional on the acceptance of female sterilisation. The providers’ attitudes in government and private health facilities were disrespectful of the women seeking abortion services. To uphold the reproductive and human rights of women who seek abortion services, we need accessible and publicly funded health care services that respect the dignity of all women, are empathetic and uphold women’s right to safe abortion services.

Medical Termination of Pregnancy (Amendment Bill, 2021): Is it Enough for Indian Women Regarding Comprehensive Abortion Care??

Medical termination of pregnancy (MTP) has been legalized in India since 1971 considering the huge burden of unsafe abortions. Even after about 50 years, Indian women continued to have unsafe abortions and face adverse and fatal consequences. At this point, only legislative amendments may not be sufficient but along with that, many other aspects need to be considered like awareness, availability, accessibility, affordability of quality MTP services, and contraceptives. People should know the adverse effects of taking unsupervised medical termination pills. Comprehensive abortion care should be provided at every level of health care to ensure the good reproductive health of the women.

Providing quality abortion care: Findings from a study of six states in India

OBJECTIVE

Although abortion has been legal in India since 1971, but very little research has been done so far on the issue of the quality of abortion services. To fill this gap, this paper examines whether the quality of abortion services provided in the country is in line with the WHO's recommendations.

STUDY DESIGN

We analyse a cross-sectional health facilities survey conducted in six Indian states, representing different sociocultural and geographical regions, as part of a study done in 2015.

MAIN OUTCOME MEASURES

Percentage of facilities offering different abortion methods, type of anaesthesia given, audio-visual privacy level, compliance with the law by obtaining woman's consent only, imposing the requirement of adopting a contraceptive method as a precondition to receive abortion.

RESULTS

Except for the state of Madhya Pradesh, fewer than half of the facilities in the other states offer safe abortion services. Fewer than half of the facilities offer the WHO recommended manual vacuum aspiration method. Only 6-26% facilities across the states seek the woman's consent alone for providing abortion. About 8-26% facilities across the states also require that women adopt some method of contraception before receiving abortion.

CONCLUSION

To provide comprehensive quality abortion care, India needs to expand the provider base by including doctors from the Ayurveda, Unani, Siddha, and Homeopathy streams as also nurses and auxiliary midwives after providing them necessary skills. Medical and nursing colleges and training institutions should expand their curriculum by offering an in-service short-term training on vacuum aspiration (VA) and medical methods of abortion.

SEXUAL AND REPRODUCTIVE HEALTH CONCERNS OF PERSONS WITH DISABILITY IN INDIA: AN ISSUE OF DEEP-ROOTED SILENCE

Global estimates suggest that over a billion people live with a disability that is significant enough to affect their daily lives. According to the 2011 Indian Census, India alone has about 26.8 million people with disabilities. Research suggests that persons with disabilities (PwDs) in India are among the most neglected, stigmatized, poor and least educated of the world's population, and women with disabilities in India are the most marginalized, both socially and economically. They bear the triple burden of being discriminated against through being 'women' (socially marginal beings), 'disabled' (incapacitated, inefficient and undesirable) and 'women with disabilities' (the weakest of the weak), often becoming socially invisible. Although there has been a general recognition over the years that the educational and employment opportunities of PwDs in India need to be improved, their sexual needs and aspirations, sexuality concerns and sexual and reproductive health and rights have been largely ignored. The objective of this paper is to highlight the paucity of research on the sexual and reproductive health concerns of PwDs, particularly women, in the Indian context using existing literature on India, and to identify the possible reasons of this neglect. The study describes the obstacles faced by PwDs, particularly women, to acquiring good sexual and reproductive information and services, based on the results of empirical studies. Given the lack of research on this in India, the evidence largely comes from studies conducted elsewhere in the world. Lack of information and education about sexual health concerns, physical and/or infrastructural inaccessibility, judgemental provider attitudes, limited provider knowledge about disability issues and individual factors, including inhibitions about seeking health care and financial barriers, are identified as factors inhibiting the sexual and reproductive rights of people with disabilities in India.

Induced Abortion: a Systematic Review and Meta-analysis

Background:

Induced abortion accounts for 1 in 8 of approximately 600000 maternal deaths that occur annually worldwide. Induced abortion rate can be considered as one of the indicators for assessing availability of the appropriate reproductive health plans for women and identifying needs for appropriate related health policies and programs.

Material and Methods:

Researchers searched Pubmed, Google Scholar, CINAHL, Embase, PsycINFO, Cochrane, Iranian Scientific Information Database (SID), Iranian biomedical journals (Iranmedex), and Iranian Research Institute of Information and Documentation (Irandoc) between January 2000 and June 2013, which reported induced abortion. Search terms from two categories including abortion and termination of pregnancy were compiled. The search terms were “induced abortion”, “illegal abortion”, “illegal abortion”, “unsafe abortion”, and “criminal abortion”. The search was also conducted with “induced termination of pregnancy”, “illegal termination of pregnancy”, “illegal termination of pregnancy”, “unsafe termination of pregnancy” and “criminal termination of pregnancy”. Meta-analysis was carried out by using OpenMeta software. Induced abortion rates were calculated based on the random effect model.

Results:

Overall induced abortion rate was obtained 58.1 per 1000 women (95%CI: 55.16-61.04). In continental level, rate of induced abortion was 14 per 1000 women (95%CI: 11-16). Nation-wide and local rates were obtained 67.27 per 1000 women (95% CI: 60.02-74.23) and 148.92 (95% CI: 140.06-157.79) respectively.

Discussion and Conclusion:

Induced abortion is a major public health problem that occurs worldwide whether under the legal restriction or freedom, and it remains as reproductive health concern globally. To eliminate the need for induced abortion is at the core of any effort for preventing this issue. Option with the highest priority is to prevent unwanted pregnancies through promoting reproductive health plans for women of reproductive age. In case the prevention strategies fail, universal provision of safe abortion services should be put in place.

Sexual violence-related pregnancies in eastern Democratic Republic of Congo: a qualitative analysis of access to pregnancy termination services

BACKGROUND

Sexual violence has been prevalent throughout the armed conflict in eastern Democratic Republic of Congo (DRC). Research on sexual violence-related pregnancies (SVRPs) and pregnancy termination in eastern DRC, a context with high prevalence of sexual violence, high maternal mortality, and restrictive abortion laws, is scant but crucial to improving the overall health of women in the DRC. Understanding women's perceptions and experiences related to an SVRP, and in particular to pregnancy termination in this context, is critical for developing effective, targeted programming.

METHODS

Respondent-driven sampling (RDS) was used to recruit two subgroups of women reporting SVRPs, 1) women raising a child from an SVRP (parenting group) and 2) women who had terminated an SVRP (termination group), in Bukavu, DRC in 2012. Semi-structured qualitative interviews on pregnancy history and outcomes were conducted with a systematically selected sub-group of women recruited through RDS methodology. Interview responses were translated, transcribed and uploaded to the qualitative data analysis software Dedoose. Thematic content analysis, complemented by the constant comparative technique from grounded theory, was subsequently used as the analytic approach for data analysis.

RESULTS

Fifty-five qualitative interviews (38 parenting group and 17 termination group) were completed. The majority of women in the termination group reported using traditional herbs to terminate the SVRP, which they often obtained on their own or through family, friends and traditional healers; whereas women in the parenting group reported ongoing pregnancies after attempting pregnancy termination with herbal medications. Three women in the termination group reported accessing services in a health center. Almost half of the women in the parenting group cited fear of death from termination as a reason for continuing the pregnancy. Other women in the parenting group contemplated pregnancy termination, but did not know where to access services. Potential legal ramifications and religious beliefs also influenced access to services.

CONCLUSIONS

Women in this study had limited access to evidence-based safe abortion care and faced potential consequences from unsafe abortion, including increased morbidity and mortality. Increased access to reproductive health services, particularly safe, evidence-based abortion services, is paramount for women with SVRPs in eastern DRC and other conflict-affected regions.

Pregnancy wastage among HIV infected women in a high HIV prevalence district of India

Background

Bagalkot district in Karnataka state is one of the highest HIV prevalence districts in India. A large proportion of the girls also marry at early age in the district and negative pregnancy outcomes among the HIV positive women likely to have large pregnancy wastages. Therefore, this study examined the pregnancy wastages and the associated factors among HIV positive women in a high prevalent district in India.

Methods

We used data from a cross-sectional survey conducted recently among randomly selected currently married HIV positive women, 15–29 years of age, in one of the high HIV prevalence districts in India. The study used the experience of reported pregnancy wastage as an outcome variable, and both bi-variate and multivariate logistic regression analyses were carried out to understand the factors associated with the pregnancy wastage among HIV infected women.

Results

Overall, 17 % of the respondents reported pregnancy wastage, of which 81 % were due to spontaneous abortions. Respondents who became pregnant since testing HIV positive reported significantly higher level of pregnancy wastage as compared to those were pregnant before they were tested for HIV. (AOR = 1.9; p = 0.00). While a positive association between duration of marriage and pregnancy wastage was noticed (AOR = 7.4; p = 0.01), there was a negative association between number of living children and pregnancy wastage (AOR = 0.24; p = 0.00). Living in a joint family was associated with increased reporting of pregnancy wastage as compared to those living in nuclear families (AOR = 1.7; p = 0.03).

Conclusions

HIV prevention and care programs need to consider the reproductive health needs of HIV infected married women as a priority area since large proportion of these women reported negative pregnancy outcomes. There is also a need to explore ways to raise the age at marriage in order to stop women getting married before the legal age at marriage.

"Yo no sabía..."-immigrant women's use of national health systems for reproductive and abortion care

Half of pregnancies worldwide are unintended; half of these end in abortion. Immigrant women encounter more obstacles to reproductive healthcare than non-immigrant women, and access to national healthcare is a particularly important factor in abortion access. Spain's government recently liberalized abortion laws, including abortion services in the national health system available to immigrants. Evidence suggests that immigrant women in Spain experience difficulties navigating the health system-the impact of the changed abortion laws on immigrant's women's access to care is not yet clear. Through a literature review and analysis, this paper examines the experiences of immigrant women with national health systems, and their use of such systems for reproductive and abortion care, in order to explore what could be expected in Spain as the national health system expands to include abortion care, and to illuminate immigrant women's experiences with using national health systems for reproductive healthcare more broadly.

Inequity in India: the case of maternal and reproductive health

Background

Millennium Development Goal (MDG) 5 is focused on reducing maternal mortality and achieving universal access to reproductive health care. India has made extensive efforts to achieve MDG 5 and in some regions much progress has been achieved. Progress has been uneven and inequitable however, and many women still lack access to maternal and reproductive health care.

Objective

In this review, a framework developed by the Commission on Social Determinants of Health (CSDH) is used to categorize and explain determinants of inequity in maternal and reproductive health in India.

Design

A review of peer-reviewed, published literature was conducted using the electronic databases PubMed and Popline. The search was performed using a carefully developed list of search terms designed to capture published papers from India on: 1) maternal and reproductive health, and 2) equity, including disadvantaged populations. A matrix was developed to sort the relevant information, which was extracted and categorized based on the CSDH framework. In this way, the main sources of inequity in maternal and reproductive health in India and their inter-relationships were determined.

Results

Five main structural determinants emerged from the analysis as important in understanding equity in India: economic status, gender, education, social status (registered caste or tribe), and age (adolescents). These five determinants were found to be closely interrelated, a feature which was reflected in the literature.

Conclusion

In India, economic status, gender, and social status are all closely interrelated when influencing use of and access to maternal and reproductive health care. Appropriate attention should be given to how these social determinants interplay in generating and sustaining inequity when designing policies and programs to reach equitable progress toward improved maternal and reproductive health.

Knowledge of termination of pregnancy (TOP) legislation and attitudes toward TOP clinical training among medical students attending two South African universities

Provision of safe, voluntary, termination of pregnancy (TOP) in South Africa is challenged by an insufficient number of TOP-trained clinicians. Medical students' understanding of TOP legality and their attitudes toward TOP training are indicators for future service provision. We administered a 63-item questionnaire to explore these issues at the University of Cape Town and Walter Sisulu University. Ordinary least squares regression assessed predictors of TOP legislation knowledge and training attitudes.

RESULTS

Of 1308 students, 95% knew that TOP was legal in South Africa, but few (27%) understood the specific provisions of the legislation beyond 13 weeks' gestation. Sixty-three percent desired more information about TOP. In multivariate models, female, white and sexually experienced students and students more advanced in school had better legislation knowledge (all p < .01). Attending religious services regularly (p < .01) was associated with lack of support for TOP training, whereas being in a relationship (p < .01) was associated with support for TOP training.

Investigating social consequences of unwanted pregnancy and unsafe abortion in Malawi: the role of stigma

Malawian women in all sectors of society are suffering from social implications of unwanted pregnancy and unsafe abortion. Unwanted pregnancies occur among women who have limited access to family planning and safe abortion. A legally restrictive setting for safe abortion services leads many women to unsafe abortion, which has consequences for them and their families. In-depth interviews were conducted with 485 Malawian stakeholders belonging to different political and social structures. Interviewees identified the impact of unwanted pregnancy and unsafe abortion to be the greatest on young women. Premarital and extramarital pregnancies were highly stigmatized; stigma directly related to abortion was also found. Community-level discussions need to focus on reduction of stigma.

Factors associated with second trimester abortion in rural Maharashtra and Rajasthan, India

Many married women in India experience abortion in their second trimester of pregnancy. While there is an impression that second trimester abortions are now overwhelmingly used for sex selection, little is known about the extent to which second trimester abortions are indeed associated with son preference and sex selection motives, relative to other factors. Using data from a community-based study in rural Maharashtra and Rajasthan, research highlights the role of limited access in explaining second trimester abortion. While women with a single child who was a daughter were indeed more likely than other women to have terminated a pregnancy carrying a female foetus in the second trimester, more strikingly, exclusion from abortion-related decision-making, unsuccessful prior attempts to terminate the pregnancy, and distance from the facility in which their abortion was performed, were significantly associated with second trimester abortion, even after controlling for confounding factors. The study calls for greater efficiency in implementing the PCPNDT Act and addressing deep-rooted son preference. At the same time, findings that poverty and limited access to facilities are as, if not more, important drivers of second trimester abortion, highlight the need to meet commitments to ensure accessible abortion facilities for poor rural women.

Women and reproductive control: the nexus between abortion and contraceptive use in Madhya Pradesh, India

This article examines the determinants of contraceptive and abortion behavior and how each of these influences the other, with an emphasis on the role of women's life-course stage and experience. We base our approach on life-course theory, which argues that behavior is influenced by current circumstances as well as experiences over the life course. We use data collected for every pregnancy experienced by 2,444 women in Madhya Pradesh, India, to explore use of temporary contraceptive methods (both modern and traditional) and sterilization, as well as abortion attempts. We use logistic regression to model whether women took these actions in a given pregnancy interval, including past experience with contraception in the abortion analyses and with abortion in the contraceptive analyses. The results suggest that life-course factors play a role in shaping behavior. Moreover, past use of contraceptives has a significant effect on attempted abortion and vice versa. Finally, we find that this relationship changes as women age and accumulate experience.

Conceptualising abortion stigma

Abortion stigma is widely acknowledged in many countries, but poorly theorised. Although media accounts often evoke abortion stigma as a universal social fact, we suggest that the social production of abortion stigma is profoundly local. Abortion stigma is neither natural nor 'essential' and relies upon power disparities and inequalities for its formation. In this paper, we identify social and political processes that favour the emergence, perpetuation and normalisation of abortion stigma. We hypothesise that abortion transgresses three cherished 'feminine' ideals: perpetual fecundity; the inevitability of motherhood; and instinctive nurturing. We offer examples of how abortion stigma is generated through popular and medical discourses, government and political structures, institutions, communities and via personal interactions. Finally, we propose a research agenda to reveal, measure and map the diverse manifestations of abortion stigma and its impact on women's health.

Regulating India's health services: to what end? What future?

India has a comprehensive legal and regulatory framework and large public health delivery system which are disconnected from the realities of health care delivery and financing for most Indians. In reviewing the current bureaucratic approach to regulation, we find an extensive set of rules and procedures, though we argue it has failed in three critical ways, namely to (1) protect the interests of vulnerable groups; (2) demonstrate how health financing meets the public interests; (3) generate the trust of providers and the public. The paper reviews the state of alternative approaches to regulation of health services in India, using consumer and market based approaches, as well as multi-actor and collaborative approaches. We argue that poor regulation is a symptom of poor governance and that simply creating and enforcing the rules will continue to have limited effects. Rather than advocate for better implementation and expansion of the current bureaucratic approach, where Ministries of Health focus on their roles as inspectorate and provider, we propose that India's future health system is more likely to achieve its goals through greater attention to consumer and other market oriented approaches, and through collaborative mechanisms that enhance accountability. Civil society organizations, the media, and provider organizations can play more active parts in disclosing and using information on the use of health resources and the performance of public and private providers. The overview of the health sector would be more effective, if Indian Ministries of Health were to actively facilitate participation of these key stakeholders and the use of information.

Unsafe abortion: the preventable pandemic

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving women's health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

A Community Health Programme in Rural Tamil Nadu, India: The Need for Gender Justice for Women

This article highlights the efforts of the Community Health and Development (CHAD) Programme of Christian Medical College to address the issues of gender discrimination and improve the status of women in the Kaniyambadi Block, Vellore, Tamil Nadu, India. The many schemes that are specifically for women and general projects for the community from which women can also benefit represent a multi-pronged approach whose aim is the improvement of women's health, education and employment in the context of community development. However, despite five decades of work with a clear bias in favour of women, the improvement in health and the empowerment of women has lagged behind that achieved by men. We believe this is because the community, with its strong male bias, utilises the health facilities and education and employment programmes more for the benefit of men and boys than women and girls. The article argues for a change of approach, in which gender and women's issues are openly discussed and debated with the community. It would appear that nothing short of social change will bring about an improvement in the health of women and a semblance of gender equality in the region.

Determinants of skilled birth attendance in rural Cambodia

OBJECTIVE

To identify the determinants of skilled and unskilled birth attendance.

METHOD

Population-based survey in a rural area in Cambodia, of women aged 15-49 years who had delivered during the previous 3-month period. An analytical framework based on Andersen's behavioural model served to identify determinants according to delivery place (facility vs. non-facility), birth attendant at home births (skilled vs. unskilled), and change of birth attendant during delivery (changed vs. unchanged). We used logistic regression to analyse the data.

RESULTS

Of 980 women included in the analyses, 19.8% had skilled attendants present during delivery. The determinants of facility delivery were different from those for having skilled attendants assisting in home births. In case of facility deliveries, previous contact with a skilled attendant through antenatal care was a significant determinant. In case of home births, the type of birth attendant (i.e. skilled or unskilled) at the preceding delivery was a significant determinant.

CONCLUSION

Community-based programmes need to reach primiparas, because once a woman has delivered with the aid of an unskilled attendant, she is five to seven times less likely to seek skilled help than a primipara.

The role of oversight in the health sector: the example of sexual and reproductive health services in India

This paper examines the role of oversight in influencing the health sector, using examples from sexual and reproductive health services in India. Rather than simply trying to provide services through traditional bureaucratic mechanisms, governments can make use of oversight tools to influence how health care is delivered through the public and private sectors. Three main oversight functions are described: understanding health system performance, deciding when to intervene in the health system and strategizing and implementing change. Governments also need to understand the ethical basis for decisions. The potential for administering oversight through policy-making, disclosing and informing, regulating, collaborating, and strategically subsidising and contracting services in sexual and reproductive health is described. This approach implies an engagement with a broader set of stakeholders in the health sector than is often the case. It requires a set of skills for public officials beyond managing public programmes, and relies on a larger role for other stakeholders and the general public. When applied to reproductive and sexual health, implementation of the full range of oversight functions offers new opportunities to provide more effective, equitable, accountable and affordable services.

Induced abortions among adolescent women in rural Maharashtra, India

In a study in rural Maharashtra, India, adolescents constituted 13.1% of the 1717 married women who had an induced abortion during an 18-month period in 1996-1998. The 197 adolescents who were subsequently interviewed had a lesser role in the decision-making process on abortion than women older than them. Most abortions were obtained in the private sector. Though spacing was the main reason for adolescents seeking abortion, prior contraceptive use among them was low. Additionally, they were less likely to receive post-abortion contraceptive counselling or to adopt contraception. Sex selection accounted for more than a fifth of abortions among adolescents. Additional qualitative data from 43 never-married and separated adolescents seeking abortion showed that non-consensual sex made many pregnancies unwanted, and cost, limited mobility, lack of family and partner support and the need for privacy to prevent stigma led many to go to traditional providers, even though safer options existed. Family planning programmes need to address the contraceptive needs of newly married adolescent women as well as unmarried adolescents. Informing adolescents of their legal rights, sensitising providers to adopt an empathetic attitude, and exploring innovative ways of increasing access to safe services for unmarried adolescents are all recommended.

Reproductive health-seeking by married adolescent girls in Maharashtra, India

In India, most adolescent girls 15-19 years old are married. A study was conducted in 1995-97 in Ahmednagar district of Maharashtra, India to gain insight into whether and how their reproductive health needs are met, especially for gynaecological problems, family planning and perceived fertility problems. It included a survey among 302 married girls of this age, and in-depth interviews with 74 girls, 37 husbands and 53 mothers-in-law. Girls were treated quickly for illnesses interfering with domestic work and were expected to conceive in the first year of marriage. Menstrual disorders and symptoms of reproductive tract infection often went untreated. There was an emerging need for delaying and spacing pregnancies; limiting the number of children was well established. Household work, protection of fertility and silence arising from embarrassment related to sexual health problems were the strongest factors influencing care-seeking. Husbands made the decision whether their wives could seek care and mothers-in-law sometimes influenced these decisions; girls had neither decision-making power nor influence. This study provides valuable input for the new reproductive and child health programme in Maharashtra.