The incidence of abortion and unintended pregnancy in India, 2015

Landscape assessment of the availability of medical abortion medicines in India

BACKGROUND

Medical abortion with mifepristone and misoprostol can be provided up to 63 days' gestation in India. This accounts for 67.5 percent of all abortions in the country. We conducted an assessment to determine the availability of medical abortion medicines, specifically the combi-pack, in India.

METHODS

We applied the World Health Organization landscape assessment protocol at the national level. The assessment protocol included a five-step adaptation of an existing availability framework, including online data collection, desk review, country-level key informant interviews, and an analysis to identify barriers and opportunities to improve medical abortion availability. The assessment was conducted between August and March 2021.

RESULTS

Medicines for medical abortion are included in the national essential drug list and available with prescription in India. The assessment identified 42 combi-pack products developed by 35 manufacturers. The quality of medical abortion medicines is regulated by national authorities; but as health is devolved to states, there are significant inter-state variations. This is seen across financing, procurement, manufacturing, and monitoring mechanisms for quality assurance of medical abortion medicines prior to distribution. There is a need to strengthen supply chain systems, ensure consistent availability of trained providers and build community awareness on use of medical abortion medicines for early abortions, at the time of the assessment.

CONCLUSION

Opportunities to improve availability and quality of medical abortion medicines exist. For example, uniform implementation of regulatory standards, greater emphasis on quality-assurance during manufacturing, and standardizing of procurement and supply chain systems across states. Regular in-service training of providers on medical abortion is required. Finally, innovations in evidence dissemination and community engagement about the recently amended abortion law are needed.

Strengthening regional commitment to ensuring access to medical abortion medicines in WHO's South-East Asia region: report of a participatory assessment and workshop

BACKGROUND

In 2019, the World Health Organization identified improving access to safe abortion as an important priority toward improving sexual and reproductive health and rights and achieving Sustainable Development Goals. One strategy for addressing this priority is strengthening access to medicines for medical abortion. All 11 countries in the South-East Asia Region have some indications for legal abortion and permit post-abortion care. Therefore, strengthening access to medical abortion medicines is a reasonable strategy for improving access to safe abortion for the Region.

METHODOLOGY

We applied an adapted version of an existing World Health Organization landscape assessment protocol for the availability of medical abortion medicines at the country-level in the South-East Asia Region. We collected publicly available data on the existence of national health laws, policies, and standard treatment guidelines; inclusion of medical abortion medicines in the national essential medicines list; and marketing authorization status for medical abortion medicines for each country and verified by Ministries of health. The findings were once more presented, discussed and recommendations were formulated during regional technical consultation workshop. Each country teams participated in the process, and subsequently, the suggestions were validated by representatives from Ministries of Health..

RESULTS

Few countries in the Region currently have national policies and guidelines for comprehensive safe abortion. However, either mifepristone-misoprostol in combination or misoprostol alone (for other indications) is included in national essential medicines lists in all countries except Indonesia and Sri Lanka. Few countries earmark specific public funds for procuring and distributing medical abortion commodities. In countries where abortion is legal, the private sector and NGOs support access to medical abortion information and medicines. Several countries only allow registered medical practitioners or specialists to administer medical abortion.

CONCLUSION

Following this rapid participatory assessment and technical consultation workshop, the World Health Organization South-East Asia Regional Technical Advisory and Sexual and Reproductive Health and Rights technical committee recommended priority actions for policy and advocacy, service delivery, and monitoring and evaluation, and indicated areas for support.

Induced abortion in Africa: A systematic review and meta-analysis

BACKGROUND

One of the main factors contributing to maternal morbidity and mortality is induced abortion. The WHO estimates that over 44 million induced abortions take place annually around the world. The majority of these abortions-about 50%-are unsafe, significantly increasing maternal morbidity and contributing to 13% of maternal deaths. Thus, this review aimed to estimate the pooled prevalence of induced abortion and its associated factors in Africa.

METHODS

To find literature on the prevalence of induced abortion and its associated factors, a thorough search of the internet databases such as PubMed/MEDLINE, African Journals Online, and Google Scholar was conducted. The data were extracted using a structured method of data collection. Software called STATA 14 was used to do the analysis. funnel plot and Egger regression test were used to evaluate potential publication bias. I2 statistics and Cochrane's Q were used to measure the heterogeneity at a p-value < 0.05.

RESULTS

976 studies were found through a thorough search of electronic databases. Finally, 46 full-text abstract papers were included in this study. The estimated pooled prevalence of induced abortion was 16% (95% CI: 13%-19%). According to the sub-group analysis, most studies were conducted in Ethiopia, and the pooled prevalence was 19% (95% CI: 10%-30%). Similarly, the subgroup analysis by year of study showed that the prevalence of induced abortion was 39% (95% CI: 17%-64%) among studies conducted in 2019.

CONCLUSION

The results of this study thus imply that the pooled prevalence of induced abortion is higher than that of earlier studies that were published in some nations. the data from this study are needed to support reproductive and adolescent health programmers and policymakers and to formulate recommendations for future clinical practice and guidelines.

Revisiting the predisposing, enabling, and need factors of unsafe abortion in India using the Heckman Probit model

Unsafe abortion refers to induced abortions performed without trained medical assistance. While previous studies have investigated predictors of unsafe abortion in India, none have addressed these factors with accounting sample selection bias. This study aims to evaluate the contributors to unsafe abortion in India by using the latest National Family Health Survey data conducted during 2019-2021, incorporating the adjustment of sample selection bias. The study included women aged 15 to 49 who had terminated their most recent pregnancy within five years prior to the survey (total weighted sample (N) = 4,810). Descriptive and bivariate statistics and the Heckman Probit model were employed. The prevalence of unsafe abortion in India was 31%. Key predictors of unsafe abortion included women's age, the gender composition of their living children, gestation stage, family planning status, and geographical region. Unsafe abortions were typically performed in the early stages of gestation, often involving self-administered medication. The primary reasons cited were unintended pregnancies and health complications. This study underscores the urgent need for targeted interventions that take into account regional, demographic, and social dynamics influencing abortion practices in India.

Life skills and reproductive health empowerment intervention for newly married women and their families to reduce unintended pregnancy in India: protocol for the TARANG cluster randomised controlled trial

INTRODUCTION

In South Asia, younger women have high rates of unmet need for family planning and low empowerment. Life skills interventions can equip young women with agency, but the effectiveness of these interventions in reproductive and sexual autonomy and contraception has not been examined.

METHODS AND ANALYSIS

A two-arm, parallel, cluster randomised controlled trial will evaluate the impact of TARANG (Transforming Actions for Reaching and Nurturing Gender Equity and Empowerment), a life skills and reproductive health empowerment group-based intervention for newly married women, compared with usual services in the community in rural and tribal Rajasthan, India. TARANG will also provide light-touch sessions to husbands and mothers-in-law of newly married women. We will test the impact of TARANG in 80 village clusters among 800 eligible households comprising newly married women aged 18-25 years who are at risk of pregnancy but do not want a pregnancy within 1 year at the time of enrolment, their husbands and mothers-in-law who consent to participate. Women in the intervention villages will receive 14 sessions over a 6-month period, while husbands and mothers-in-law will receive 1 and 4 sessions (respectively) each. Three rounds of surveys will be collected over 18 months. Control villages will receive the intervention after the endline surveys. Primary outcomes include rate of unintended pregnancy and modern contraceptive use. We plan to start recruitment of participants and data collection in April 2024. We will estimate unadjusted and adjusted intention-to-treat effects using survival analysis and mixed models.

ETHICS AND DISSEMINATION

Study protocols have been reviewed and approved by the human subjects review boards at the University of California, San Francisco, and the Centre for Media Studies, India (IRB00006230) and ACE Independent Ethics Committee, Bangalore (NET0062022). Results will be disseminated in international peer-reviewed journals and conferences, to stakeholders including local government and non-governmental organisations, and directly to the communities and individuals that participated in the intervention.

TRIAL REGISTRATION NUMBER

NCT06024616.

Understanding trimester-specific miscarriage risk in Indian women: insights from the calendar data of National Family Health Survey (NFHS-5) 2019-21

BACKGROUND

The primary public health issue, especially in low- and middle-income countries, is early pregnancy loss driven by miscarriage. Understanding early pregnancy losses and the characteristics of mothers who have miscarriages is essential to creating effective reproductive health strategies. Thus, this study's primary goal is to delve into the factors which impact miscarriages that take place prior to and following the first 12 weeks of gestation.

METHODS

The bivariate analysis was employed to determine the frequency of miscarriages. The factors associated with miscarriages in the first (≤12 weeks) and second & above (> 12 weeks) trimesters of pregnancy were then examined using a generalised linear regression model, with 95% confidence intervals. Finally, we use ArcGIS to illustrate the prevalence of miscarriage in the districts of India.

RESULTS

Our result shows that miscarriages occur often in India (4.9%), with 23% of cases occurring in the first trimester (≤12 weeks). In our bivariate analysis, we identified several factors associated with a higher prevalence of miscarriages in India. It was found that mothers aged thirty years or older, residing in urban areas, with less than ten years of education, belonging to the richest wealth quantile, expressing a desire for more children, having no demand for contraception, and possessing no parity experienced a higher prevalence of miscarriage in total pregnancies in India. On the other hand, the generalised linear model's findings show that mothers who are thirty years of age or older, practise other religions, live in urban areas, are members of other castes, want more children, marry before the age of eighteen, and meet their contraceptive needs are more likely to have miscarriages in total pregnancy. However, there is a larger likelihood of miscarriage in the first trimester (≤12 weeks) for mothers who follow other religions, live in urban areas, are from Other Backward Class (OBC), get married before the age of eighteen, and fall into the middle and upper wealth quantiles. A mother is more likely to miscarriage in the second & above (> 12 weeks) trimesters if she is older than thirty, from other castes, wants more children, has moderate media exposure, marries before turning eighteen, meets her contraceptive needs, and does not feel the need for contraception. After accounting for socioeconomic characteristics, all results were statistically significant.

CONCLUSIONS

Given the substantial number of miscarriages in India, police need to improve planning and guidance in order to lower pregnancy loss due to miscarriage. Miscarriage rates may be significantly decreased by enhancing the availability and quality of reproductive health care infrastructure, particularly in rural areas.

The impact of accredited social health activists in India on uptake of modern contraception: A nationally representative multilevel modelling study

The government of India introduced the Accredited Social Health Activist (ASHA) programme in 2006 to connect marginalised communities to the health system. ASHAs are mandated to increase the uptake of modern contraception through the doorstep provision of services. There is currently no evidence on the impact of ASHAs on the uptake of contraception at the national level. This paper examines the impact of ASHAs on the uptake of modern contraception using nationally representative National and Family Health Survey data collected in 2019-21 in India. A multilevel logistic regression analysis was performed to determine the effect of contact with ASHAs on the uptake of modern contraception, controlling for regional variability and socio-demographic variables. The data provide strong evidence that ASHAs have succeeded in increasing modern contraceptive use. Women exposed to ASHAs had twice the odds of being current users of modern contraception compared to those with no contact, even after controlling for household and individual characteristics. However, only 28.1% of women nationally reported recent contact with ASHA workers. The ASHA programme should remain central to the strategy of the government of India and should be strengthened to achieve universal access to modern contraception and meet sustainable development goals by 2030.

The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries

Previous studies have found high levels of unintended pregnancy among female sex workers (FSW), but less attention has been paid to their abortion practices and outcomes. This study is the first to investigate abortion-related mortality among FSW across eight countries: Angola, Brazil, Democratic Republic of Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa. The Community Knowledge Approach (CKA) was used to survey a convenience sample of FSW (n = 1280). Participants reported on the deaths of peer FSW in their social networks during group meetings convened by non-governmental organisations (n = 165 groups, conducted across 24 cities in 2019). Details on any peer FSW deaths in the preceding five years were recorded. The circumstances of abortion-related deaths are reported here. Of the 1320 maternal deaths reported, 750 (56.8%) were due to unsafe abortion. The number of abortion-related deaths reported was highest in DRC (304 deaths reported by 270 participants), Kenya (188 deaths reported by 175 participants), and Nigeria (216 deaths reported by 312 participants). Among the abortion-related deaths, mean gestational age was 4.6 months and 75% occurred outside hospital. Unsafe abortion methods varied by country, but consumption of traditional or unknown medicines was most common (37.9% and 29.9%, respectively). The 750 abortion-related deaths led to 1207 children being left motherless. The CKA successfully recorded a stigmatised practice among a marginalised population, identifying very high levels of abortion-related mortality. Urgent action is now needed to deliver comprehensive sexual and reproductive healthcare to this vulnerable population, including contraption, safe abortion, and post-abortion care.

Estimating induced abortion incidence and the use of non-recommended abortion methods and sources in two provinces of the Democratic Republic of the Congo (Kinshasa and Kongo Central) in 2021: results from population-based, cross-sectional surveys of reproductive-aged women

The changing abortion legal and practice landscape in the DRC in recent years calls for a re-examining of induced abortion experiences. The current study provides population-level estimates of induced abortion incidence and safety by women's characteristics in two provinces using direct and indirect approaches to assess indirect method performance. We use representative survey data on women aged 15-49 in Kinshasa and Kongo Central collected from December 2021 to April 2022. The survey had questions on respondents' and their closest friends' experience with induced abortion, including methods and sources used. We estimated one-year abortion incidence and proportion using non-recommended methods and sources overall and by background characteristics for each province separately for respondents and friends. The fully adjusted one-year friend abortion rate was 105.3 per 1000 women of reproductive age in Kinshasa and 44.3 per 1000 in Kongo Central in 2021; these were substantially higher than corresponding respondent estimates. Women earlier in their reproductive lifespan were more likely to have had a recent abortion. Approximately 17.0% of abortions in Kinshasa and one-third of abortions in Kongo Central involved non-recommended methods and sources according to respondent and friend estimates. The more accurate friend abortion incidence estimates indicate that women in the DRC often rely on abortion to regulate their fertility. Many use non-recommended means and sources to terminate, thus, significant work remains to actualise the commitments made in the Maputo Protocol to provide comprehensive reproductive health services that combine primary and secondary prevention services to reduce unsafe abortion and its consequences.

Impact of the Covid-19 Pandemic on the Prevalence of MTP Cases and Their Clinicodemographic Profile in India: A Retrospective Multicentric Study

Background

During the Covid-19 pandemic, reproductive health of women was disproportionately affected due to difficult access to safe abortion and contraceptive services. This study aims to assess the impact of the Covid-19 pandemic on the prevalence of MTP cases and to find out the clinicodemographic profiles of women undergoing MTP during three Covid-waves in different hospitals-Government and private sectors in India.

Methods

This retrospective multicentric cohort study was conducted during three Covid-19 pandemic waves. The records were retrieved from the centers' medical record section and the MTP register from the Department of Obstetrics and Gynaecology.

Results

On an average, 1.1 women/day underwent MTP during covid waves compared to 1.9 women/day during the pre-covid 2019. The first Covid wave's average MTP/day was very low (0.71) compared to the third (2.88) and second wave (1.12), respectively. These differences were statistically significant (p<0.0001). The most common indication for MTP was contraceptive failure 245(50.9%), followed by eugenic/congenital anomalies 88(18.9%). A total of 244 cases (50.6%) reported for MTP ≤ seven weeks and 114(23.6%) presented between 7 and 12 weeks. More than half (54%) of the women underwent surgical methods for abortion as the unavailability of medical abortion (MA) drugs. IUCD and sterilization were severely affected during the first and second Covid waves.

Conclusion

Safe abortions are essential services for reproductive-age women. With the uncertainty of future Covid-like an emergency, we should strengthen our telemedicine network so that women can reach out early and MMA can be initiated to reduce the number of surgical abortions and unwanted pregnancies.

Neonatal, Infant, and Child Mortality in India: Progress and Future Directions

In India, considerable progress has been made in reducing child mortality rates. Despite this achievement, wide disparities persist across and socio-economic strata, and persistent challenges, such as malnutrition, poor sanitation, and lack of clean water. This paper provides a comprehensive review of the state of child health in India, examining key risk factors and causes of child mortality, assessing the coverage of child health interventions, and highlighting critical public health programs and policies. The authors also discuss future directions and recommendations for bolstering ongoing efforts to improve child health. These include state- and region-specific interventions, prioritizing social determinants of health, strengthening data systems, leveraging existing programs like the National Health Mission (NHM) and Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), and the proposed Public Health Management Cadre (PHMC). The authors argue that reducing child mortality requires not only scaled-up interventions but a comprehensive approach that addresses all dimensions of health, from social determinants to system strengthening.

Developing and validating an abortion care quality metric for facility and out-of-facility settings: an observational cohort study in Bangladesh, Ethiopia, and Nigeria

Background

Despite progress in assuring provision of safe abortion, substantial disparities remain in quality of abortion care around the world. However, no consistent, valid, reliable method exists to routinely measure quality in abortion care across facility and out-of-facility settings, impeding learning and improvement. To address this need, the Abortion Service Quality Initiative developed the first global standard for measuring quality of abortion care in low-income and middle-income countries.

Methods

This prospective cohort study was conducted in Bangladesh, Ethiopia, and Nigeria in 2020-2022. Participants included sites and providers offering abortion care, including health facilities, pharmacies, proprietary and patent medicine vendors (PPMVs), and hotlines, and clients aged 15-49 receiving abortion care from a selected site. 111 structure and process indicators were tested, which originated from a review of existing abortion quality indicators and from qualitative research to develop additional client-centred quality indicators. The indicators were tested against 12 clinical and client experience outcomes at the site-level (such as abortion-related deaths) and client-level (such as whether the client would recommend the service to a friend) that were expected to result from the abortion quality indicators. Indicators were selected for the final metric based on predictive validity assessed using Bayesian models to test associations between indicators and outcomes, content validity, and performance.

Findings

We included 1915 abortion clients recruited from 131 sites offering abortion care across the three countries. Among the 111 indicators tested, 44 were associated with outcomes in Bayesian analyses and an additional 8 were recommended for inclusion by the study's Resource Group for face validity. These 52 indicators were evaluated on content validity, predictive validity, and performance, and 29 validated indicators were included in the final abortion care quality metric. The 29 validated indicators were feasibility tested among 53 clients and 24 providers from 9 facility sites in Ethiopia and 57 clients and 6 PPMVs from 9 PPMV sites in Nigeria. The median time required to complete each survey instrument indicated feasibility: 10 min to complete the client exit survey, 16 min to complete the provider survey, and 11 min to complete the site checklist. Overall, the indicators performed well. However, all providers in the feasibility test failed two indicators of provider knowledge to competently complete the abortion procedure, and these indicators were subsequently revised to improve performance.

Interpretation

This study provides 29 validated abortion care quality indicators to assess quality in facility, pharmacy, and hotline settings in low-income and middle-income countries. Future research should validate the Abortion Care Quality (ACQ) Tool in additional abortion care settings, such as telemedicine, online medication abortion (MA) sellers, and traditional abortion providers, and in other geographical and legal settings.

Funding

The David and Lucile Packard Foundation and the Children's Investment Fund Foundation.

Self-managed medication abortion trajectories: results from a prospective observational study in Argentina, Nigeria and Southeast Asia

OBJECTIVES

Time is a crucial factor in abortion-seeking because options for care change with pregnancy duration, and most people prefer to access abortion care early in pregnancy. We aimed to collect data on the timing of steps in accompanied self-managed abortion-seeking experiences in legally restrictive settings.

METHODS

In this prospective, observational, cohort study we recruited callers from three abortion accompaniment groups in Argentina, Nigeria and a country in Southeast Asia. Participants completed a baseline survey before starting a self-managed medication abortion (SMA) and two follow-up surveys (approximately 1 and 3 weeks after taking medication). Primary outcomes of interest included: (1) time from abortion decision to contacting the hotline, (2) time from contacting the hotline to obtaining pills and (3) time from obtaining pills to taking the first dose. We explored relationships between participant characteristics and each of these outcomes and evaluated differences in overall abortion time using survival analyses.

RESULTS

Between July 31, 2019 and October 01, 2020 we enrolled 1352 eligible callers; 1148 provided data for this analysis. After deciding to have an abortion, participants took 12.2 days on average (95% CI: 11.6, 12.9) to start medications for abortion. On average, participants at later pregnancy durations progressed through the SMA process more quickly (<4 weeks: 20.9 days, 4 weeks: 11 days, 5-6 weeks: 10.1 days, 7-9 weeks, 10.4 days, 10+ weeks: 9.1 days; p<0.001).

CONCLUSIONS

Overall, participants accessed accompaniment group support and started abortion regimens quickly and at relatively early pregnancy durations. SMA with accompaniment provided a time-efficient route for obtaining abortions.

Randomised Control Study of Misoprostol and Mifepristone versus Misoprostol Alone in Second Trimester Termination of Pregnancy

Introduction

This study was done to assess and compare the efficacy and safety of mifepristone and misoprostol combination versus misoprostol alone for second trimester termination of pregnancy in relation to induction abortion interval, average amount of misoprostol required in each group, success rate and side effects.

Materials and Methods

This randomised control study was conducted on 100 women admitted in the Department of Obstetrics & Gynaecology, S.C.B. Medical College & Hospital, Cuttack, for second trimester termination of pregnancy, divided into two groups, Group A and Group B of 50 patients each. Group A patients received 200 mg of oral mifepristone followed by 400 mcg of vaginal misoprostol after 48 h, and then 400 mcg of vaginal misoprostol every 3 hourly until complete expulsion or up to a maximum of 6 doses. Group B patients received 400 mcg of vaginal misoprostol every 3 hourly until complete expulsion or up to maximum 6 doses.

Results

Complete abortion was seen in 92% and 72% cases in Group A and Group B, respectively. Mean induction abortion interval was 11.59 ± 2.71 h in Group A and 15.57 ± 2.27 h in Group B (p value < 0.001). The average dose of misoprostol required was less in combination regimen, i.e. 1128 ± 384 mcg compared to 1680 ± 302 mcg in misoprostol alone group (p value < 0.001). Side effects like nausea, vomiting and diarrhoea were less in combination regimen than misoprostol alone group.

Conclusion

Mifepristone and misoprostol combination is more effective and safer alternative than misoprostol alone in second trimester termination of pregnancy.

The Association Between Self-Managed versus Clinician-Managed Abortion and Self-Reported Abortion Complications: A Cross-Sectional Analysis in India

Purpose

To examine the association between self-managed abortion and the self-reported experience of abortion complications in India, a country with a high incidence of self-managed abortion.

Patients and Methods

The study used a cross-sectional multivariable logistic regression analysis of data from the National Family Health Survey (NFHS-4) of 2015-2016 to compare the odds of self-reported complications experienced during abortion between self-managed and clinician-managed abortions in India.

Results

On average, self-managed abortions occurred earlier in gestation than clinician-managed abortions, 7.8 weeks and 11.3 weeks, respectively (p < 0.001). Self-managed abortion was associated with fewer self-reported abortion-related complications than clinician-managed abortions when adjusted for covariates not including gestational age (Adjusted Odds Ratio (aOR) 0.82, 95% confidence interval (CI) 0.69, 0.97). However, once adjusted for gestational age, there was no longer a clinically meaningful or statistically significant difference in the odds of self-reported complications between self-managed and clinician-managed abortions (aOR = 0.98, 95% CI 0.81, 1.18).

Conclusion

These findings suggest that people in India are using safe methods to self-manage abortions and support the hypothesis that self-managed abortion can improve access to abortion and reproductive choice without increasing risk.

Study of pre-conception care (PCC) amongst women in the first trimester coming to the obstetrics and gynaecology (OBGY) outpatient department (OPD) of a hospital in a rural area

Background

Pre-conception care (PCC) is a set of interventions that aim to identify and modify biomedical, behavioural and social risks to women's health and pregnancy outcomes.

Materials and Methods

It was an observational descriptive cross-sectional study conducted in the obstetrics and gynaecology (OBGY) outpatient department (OPD) of a tertiary care teaching institute in a rural set-up. Two hundred women in the first trimester of pregnancy were interviewed using a pre-designed and pretested questionnaire following informed verbal consent. The study was conducted between May and September 2019. The study excluded women in the 2nd or 3rd trimester of pregnancy, inpatient department (IPD) patients and those unwilling to participate.

Results

The study revealed that 25.5% of the women had conceived between 14 and 19 years of age. Fifty-four percent of the pregnancies were unplanned. Merely 14.5% had consulted and 15% had their laboratory investigations performed before pregnancy. Only 11% had received pre-conception folic acid supplementation. Pregnancies with birth spacing <2 years accounted for 15%. The proportion of women with known risk factors was 38% being underweight, 9.5% being overweight, 8% being of short stature (height ≤145 cm), 63% having anaemia (haemoglobin <12 g/dL), 10% with a previous history of abortion, 3.5% with systemic diseases, 4.5% with poor oral hygiene, 1% with domestic violence, 3% with medication, 3% with tobacco addiction and 4.5% with radiation/environmental toxin exposure. One percent had the hepatitis B vaccine and 0.5% had the influenza vaccine.

Conclusion

From our study, we conclude that the PCC services are meagre, and unhealthy women who conceive without adequate PCC are prone to maternal and foetal health complications.

Understanding the healthcare provider role on post abortion contraception adoption in India using National Family Household Survey-5

BACKGROUND

Post abortion contraceptive use is an important area in provisioning of services associated with child birth planning. This study examines the factors related to the type and timing of initiation of contraception adoption among women who had undergone induced abortion. Study also tries to identify the role of personnel who provided the abortion service on decision of family planning adoption using complementary log-log model in India.

METHODOLOGY

The study uses the secondary data from the fifth round of the National Family Household Survey conducted during 2019-21. For, the analysis, we have used five-year women's reproductive calendar to extract information on contraceptive use, post last induced abortion among women. We used complementary log-log regression models, to estimate relative risk ratios and its 95% Confidence intervals (CI).

RESULTS

According to NFHS-5, out of all the last pregnancies (2,55,549), about three percent resulted in abortion. Most of the abortion occurred in private facilities (55%), with the help of health professionals (71%). From the women's reproductive calendar, it was found that around 40% of the women adopted modern methods of contraception, with maximum adopting spacing method (33%), and only handful adopted permanent method (7%). It was also found that the likelihood of early adoption of permanent method increased to two times when the abortion is done by health professional compared to others [95% CI (1.25-3.30)].

CONCLUSION

This emphasises a need for quality counselling related to timing and types of family planning as an essential part of the family planning program ensuring client centric approach suited to their needs and contexts that helps in alleviating any apprehensions associated with adverse effects of modern contraceptive methods.

Inclusion of abortion-related care in national health benefit packages: results from a WHO global survey

INTRODUCTION

Service inclusion in a country's health benefit package (HBP) is an important milestone towards universal health coverage. This study aimed to explore HBP inclusion of abortion interventions globally.

METHODS

Secondary analysis of the WHO HBP survey, in which officially nominated survey focal points were asked which interventions were included within the HBP of their country or area's largest government health financing scheme. Abortion inclusion was compared by region, income, legal status of abortion and HBP design process variables. Abortion inclusion was compared with other sexual and reproductive health (SRH) services.

RESULTS

Below half (45%) reported that abortion is included, but treatment of complications from unsafe abortion was more commonly included (63%). Fewer fully included essential abortion medications (22% mifepristone, 42% misoprostol). Abortion was less commonly included than any other SRH service in the survey. Unlike most SRH services, higher cost, higher technology care to treat complications of unsafe abortion was more commonly included than the relatively lower cost, lower technology service of induced abortion. Higher-income contexts and less restrictive legal environments had higher abortion inclusion. Some contexts had additional restrictions, with abortion inclusion dependent on the patient's reason for seeking care.

CONCLUSION

This global survey finds that abortion services and medications are often not included within HBPs, while treatment of complications from unsafe abortion is more commonly included. There are opportunities to improve HBP abortion inclusion across different legal contexts, which can improve health outcomes and reduce the need for higher cost treatment of complications from unsafe abortion.

Patterns and Predictors of Abortion Care-Seeking Practices in India: Evidence From a Nationally Representative Cross-Sectional Survey (2019-2021)

Background India continues to have unsafe abortions despite progressive legislation since the past five decades facilitating ease of access to abortion services. This study describes abortion care-seeking patterns (social/therapeutic/humanitarian/sex-selective/safe/unsafe), preferences (public/private/at home), and their determinants among Indian women. Methods Data were taken from the Indian National Family and Health Survey (NFHS-5) (2019-2021) including women aged 15-49 years, who had terminated their last pregnancy by induced abortion within five years prior to the survey (N = 5,856). A bivariate analysis, followed by a multinomial logistic regression model, was performed to assess the predictors affecting the choice of healthcare facility type for an abortion. Predictors of unsafe and self-managed abortions were examined using binary logistic regression. Results About 665,671 women in the reproductive age group responded to the survey, of which 3.42% (n=22,767) reported their most recent pregnancy within the last five years terminated in either a miscarriage, stillbirth or abortion, of which 5,856 (25.72%) underwent an induced abortion. Women undergoing surgical abortion were more likely to avail of either a public (adjusted relative risk ratio (aRRR)=38.06 (23.62, 61.35)) or a private facility (aRRR=44.53 (28.11,70.53)) compared to at-home abortions. Women reporting a social and humanitarian reason for abortion were less likely to undergo an abortion at a public (aRRR=0.25 (0.17,0.35)) or private facility (aRRR=0.32 (0.23,0.44)) than at home. Furthermore, a total of 147 (2.43%) abortions were classified as unsafe. Women reporting sex-selective reasons for abortion were observed to have a higher likelihood of engaging in an unsafe abortion (adjusted odds ratio (aOR)= 1.61 (0.70, 3.70)) compared to those citing a therapeutic reason. Conclusions Self-managed abortions at home were more prevalent in women of lower socioeconomic status, adolescent girls, and those reporting sex-selective reasons for abortion. Furthermore, the reproductive-health program in India should enhance capacity-building initiatives for primary-care healthcare providers, including doctors, nurses, and pharmacists, to effectively prescribe and supervise abortion through medication methods.

Medical Termination of Pregnancy Act of India: Treading the Path between Practical and Ethical Reproductive Justice

One of the most important facets of reproductive freedom and justice is the right to abortion. For centuries, the debate on legalisation and regulation of abortion has caused ethical dilemmas with proponents for both sides of the argument. India, a developing nation, with a wide spectrum of cultures, traditions, socio-economic statuses and religious beliefs, would be expected to be grappling with this problem. However, India since the 1970s made a clear stance on the matter of abortion. Respecting the right to personal liberty, reproductive freedom of women and upholding the importance of women's health, Medical Termination Pregnancy (MTP) has been legal in India since 1971. We look at the laws governing MTP in India, the practical and ethical considerations, the recent amendments in these laws and the road ahead.

Changes in Socioeconomic Inequalities in Unintended Pregnancies Among Currently Married Women in India

Background

Despite the consistent prevalence of unintended pregnancies in India and its adverse impact on maternal and neonatal mortality, the literature discussing socioeconomic inequality remains scarce. This study aims to assess the change in wealth-related inequalities in unintended pregnancy in India from 2005-2006 to 2019-20 and to quantify the contribution of various factors towards inequality.

Methods

The present study analyzed cross-sectional data from the third and fifth rounds of the National Family Health Survey (NFHS). The information on fertility preferences and pregnancy intention of most recent live birth during the five years preceding the survey was collected from eligible women. The concentration index and Wagstaff decomposition were used to analyze wealth-related inequality and the contributing factors.

Results

Our results show that the prevalence of unintended pregnancy has declined in 2019-20 to 8% from 22% in 2005-2006. With the increase in education and wealth status, unintended pregnancy decreases significantly. The results of the concentration index depict that unintended pregnancy is more concentrated among the poor than the rich in India, and the individual's wealth status has the highest contribution to unintended pregnancy inequality. Other factors like mothers' BMI, place of residence and education also contribute majorly to the inequality.

Conclusions

The study results are critical and increase the need for strategies and policies. Disadvantaged women need education and family planning information, plus access to reproductive health resources. Governments should improve accessibility and quality of care in family planning methods to prevent unsafe abortions, unwanted births, and miscarriages. Further research is needed to investigate the impact of social and economic status on unintended pregnancies.

The burden of unintended pregnancies among Indian adolescent girls in Bihar and Uttar Pradesh: findings from the UDAYA survey (2015-16 & 2018-19)

BACKGROUND

Unintended pregnancy severely affects the health and welfare of women and children, specifically if women are young and vulnerable. This study aims to determine the prevalence of unintended pregnancy and its determinants among adolescent girls and young adult females in Bihar and Uttar Pradesh. We believe the present study is unique as it examines the association between unintended pregnancy and sociodemographic factors among young female population in two states of India from 2015-19.

METHODS

The data for the present study is derived from the two-wave longitudinal survey "Understanding the lives of adolescents and young adults" (UDAYA) conducted in 2015-16 (Wave 1) and 2018-19 (Wave 2). Univariate, bivariate analysis along with logistic regression models were employed.

RESULTS

The results revealed that 40.1 per cent of all currently pregnant adolescents and young adult females reported their pregnancy as unintended (mistimed and unwanted) in Uttar Pradesh at Wave 1 of the survey, which decreased to 34.2 per cent at Wave 2. On the contrary, almost 99 per cent of all currently pregnant adolescents in Bihar reported their pregnancy as unintended at Wave 1, which decreased to 44.8 per cent at Wave 2. The sociodemographic factors like age, caste, religion, education, wealth, media and internet use, knowledge and effective contraception highly impacted unintended pregnancy in Bihar and Uttar Pradesh. The longitudinal results of the study revealed that place of residence, internet use, number of wanted children, heard about contraception and SATHIYA, use of contraception, side effects of contraception, and the confidence in getting contraceptives from ASHA/ANM did not appear significant predictors at Wave 1. However, they emerge significant over time (Wave 2).

CONCLUSIONS

Despite many recently launched policies for adolescents and the youth population, this study comprehended that the level of unintended pregnancies in Bihar and Uttar Pradesh stands worrisome. Therefore, adolescents and young females need more comprehensive family planning services to improve their awareness and knowledge about contraceptive methods and use.

Gestational Trophoblastic Neoplasia-A Retrospective Analysis of Patients Treated at a Tertiary Care Oncology Center in North India

Anuj GuptaObjectives  The aim of this study was to do a retrospective analysis of patients of gestational trophoblastic neoplasia (GTN) treated at our center concerning their clinical features and treatment outcomes. Materials and Methods  Patients diagnosed and treated from May 2018 to December 2021 were included. All relevant information pertaining to eligible patients was retrieved from the electronic medical records. Patients were risk-stratified based on the World Health Organization (WHO) risk scoring system with a score of seven and above being classified into the high-risk category. Patients were monitored for response by measuring β-human chorionic gonadotrophin (β-HCG) levels before each consecutive cycle. Statistical Analysis  Appropriate statistical analysis was performed using SPSS version 26. Results  Records of 39 eligible patients were analyzed for clinical features out of which 38 were eligible for response assessment. The median age of presentation was 28 years with the majority of patients (79.4%) diagnosed based on β-HCG levels and clinical history alone. The most common symptom was bleeding per vagina (64%), while the majority of antecedent pregnancies were abortions (59%). Of the 14 low-risk category patients, 12 received single-agent methotrexate/actinomycin D, while 2 received etoposide, methotrexate actinomycin D (EMACO) regimen. Overall response rates were 85.7% with the others responding to the second-line EMACO regimen. Five patients in this group had a WHO score of 5 or 6 and all of them responded to single-agent treatment. Among the 25 high-risk category patients, all received the EMACO regimen with high-dose methotrexate added to those with brain metastasis. The response rate was 87.5% with all the nonresponders having features of ultra-high risk of liver/brain metastasis and/or a WHO score of more than 12. While one nonresponder had expired despite treatment, the other two responded to the etoposide methotrexate and actinomycin D/ etoposide and cisplatin regimen. Conclusion  Our results are in consonance with other reported studies. The subcategories of low-risk GTN with a WHO score of 5 and 6 and high-risk GTN with ultra-high-risk features deserve further research in the form of multicenter prospective studies.

Negotiating Autonomy: The Linkages between Intimate Partner Violence, Women’s Paid Work Status and Birth Outcomes

Maternal and child health is severely impacted by adverse birth outcomes leading to a public health concern. A whole host of socioeconomic factors are instrumental in determining birth outcomes. Importantly, there is an intricate relationship between women’s autonomy, the perpetration of intimate partner violence in households, women’s paid work status and their consequent impact on birth outcomes. Noting this, we ask how intimate partner violence and women’s work status interact and how women’s ‘autonomy’ is negotiated to mitigate adverse birth outcomes such as miscarriage, abortion, stillbirth, low birth weight and preterm birth. We use the nationally representative NFHS-5 data for India and use multiple correspondence analyses to create an index of women’s autonomy, and multinomial logistic regression has been used to determine the relation. Women’s working status in association with the perpetration of intimate partner violence contributes significantly to adverse birth outcomes. The study found that mitigation of adverse birth outcomes, which is necessary for bringing about improvements in maternal and child health, is contingent on a multiplicity of social factors, which requires redressal in association to ensure a reduction in adverse birth outcomes.

Pregnancy outcomes among Indian women: increased prevalence of miscarriage and stillbirth during 2015-2021

BACKGROUND

Pregnancy outcome is an important health indicator of the quality of maternal health. Adverse pregnancy outcomes is a major public health problem, which can lead to poor maternal and neonatal outcomes. This study investigates the trends in pregnancy outcomes prevalent during 2015-2021 in Indian women.

METHODS

The study analysed the data presented in the fourth (2015-16) and fifth (2019-21) rounds of National Family Health Survey (NFHS). The absolute and relative changes in the birth outcomes of last pregnancy during the five years preceding the surveys were estimated using data collected from 195,470 women in NFHS-4 and from 255,549 women in NFHS-5.

RESULTS

Livebirth decreased by 1.3 points (90.2% vs. 88.9%), and nearly half of the Indian states/UTs (n = 17/36) had lower than the national average of livebirth (88.9%) reported during 2019-21. A higher proportion of pregnancy loss was noted, particularly miscarriages increased in both urban (6.4% vs. 8.5%) and rural areas (5.3% vs. 6.9%), and stillbirth increased by 28.6% (0.7% vs. 0.9%). The number of abortions decreased (3.4% vs. 2.9%) among Indian women. Nearly half of the abortions were due to unplanned pregnancies (47.6%) and more than one-fourth (26.9%) of abortions were performed by self. Abortions among adolescent women in Telangana was eleven times higher during 2019-21 as compared to 2015-16 (8.0% vs. 0.7%).

CONCLUSION

Our study presents evidence of a decrease in the livebirth and an increase in the frequency of miscarriage and stillbirth among Indian women during 2015-2021. This study emphasises that there is a need of regional-specific, comprehensive and quality maternal healthcare programs for improving livebirth among Indian women.

Menstrual regulation: examining the incidence, methods, and sources of care of this understudied health practice in three settings using cross-sectional population-based surveys

BACKGROUND

Menstrual regulation is a practice that may exist within the ambiguity surrounding one's pregnancy status and has been the subject of limited research. The aim of this study is to measure the annual rate of menstrual regulation in Nigeria, Cote d'Ivoire, and Rajasthan, India, overall and by background characteristics and to describe the methods and sources women use to bring back their period.

METHODS

Data come from population-based surveys of women aged 15-49 in each setting. In addition to questions on women's background characteristics, reproductive history, and contraceptive experiences, interviewers asked women whether they had ever done something to bring back their period at a time when they were worried they were pregnant, and if so, when it occurred and what methods and source they used. A total of 11,106 reproductive-aged women completed the survey in Nigeria, 2,738 in Cote d'Ivoire, and 5,832 in Rajasthan. We calculated one-year incidence of menstrual regulation overall and by women's background characteristics separately for each context using adjusted Wald tests to assess significant. We then examined the distribution of menstrual regulation methods and sources using univariate analyses. Method categories included surgery, medication abortion pills, other pills (including unknown pills), and traditional or "other" methods. Source categories included public facilities or public mobile outreach, private or non-governmental facilities or doctors, pharmacy or chemist shops, and traditional or "other" sources.

RESULTS

Results indicate substantial levels of menstrual regulation in West Africa with a one-year incidence rate of 22.6 per 1,000 women age 15-49 in Nigeria and 20.6 per 1,000 in Cote d'Ivoire; women in Rajasthan reported only 3.3 per 1,000. Menstrual regulations primarily involved traditional or "other" methods in Nigeria (47.8%), Cote d'Ivoire (70.0%), and Rajasthan (37.6%) and traditional or "other" sources (49.4%, 77.2%, and 40.1%, respectively).

CONCLUSION

These findings suggest menstrual regulation is not uncommon in these settings and may put women's health at risk given the reported methods and sources used. Results have implications for abortion research and our understanding of how women manage their fertility.

Legal Limits Relaxed: Time to Look at Other Barriers Faced by Women Seeking Termination of Pregnancy for Fetal Anomalies

Introduction Advancements in prenatal diagnostic techniques have led to an increase in demand for termination of pregnancy for fetal anomalies (TOPFA). While relaxation in the legal gestational age limits across various countries relieves an important barrier, there is a need to identify the reasons that lead to delays in seeking abortion for fetal anomalies, because abortion-related complications increase with gestational age. Methods In this hospital-based qualitative study, antenatal women referred to a tertiary care institute in North India because of major fetal anomalies were explained about the study. Those women who fulfilled the inclusion criteria were recruited after taking consent. Details of antenatal care and prenatal tests were recorded. An in-depth inquiry was made into the reasons for the delay in prenatal tests, the delay in the decision for abortion, and specific problems that they faced in seeking TOPFA. Results Out of 80 women who met the inclusion criteria and consented to participate, more than 75% had received antenatal care in public healthcare facilities. Less than 50% of women received folic acid in the first trimester while 26% had first contact with healthcare facilities in the second trimester. Only 21 women underwent screening for common aneuploidies. Second-trimester anomaly scan was delayed in 35 women due to women-centered reasons (n = 17) or provider-centered (n = 19) reasons. Only 37.5% of women were counseled about fetal anomalies by their primary care provider. Owing to delay at multiple levels, 40 women (50%) could receive counseling about fetal abnormality for the first time after 20 weeks. These women could not be offered abortion because this study was carried out before the amendments in the Medical Termination of Pregnancy Act in India. The older act allowed abortion up to 20 weeks of gestation. Seventeen women could obtain permission for an abortion from a court of law. Arrangements for travel and stay and dependence on family members were the main problems faced by women seeking TOPFA. Conclusions Delay in diagnosis of a fetal anomaly due to delay in seeking antenatal care, irregular follow-up, and lack of pre-test counseling are the major reasons for the delay in the decision for abortion. This is further compounded by inadequate post-test counseling. Lack of awareness, failure or delay in counseling, need to travel to another facility for abortion, dependence on family members, and financial issues are the major barriers.

Study protocol: 'a large cohort study of postnatal events in a not-for-profit referral centre in Vellore, South India'

INTRODUCTION

In a large developing country, with diverse population characteristics and differential access to healthcare, it is important to identify factors that influence postnatal health. This knowledge will help frame recommendations to enhance universal postnatal care.

METHODS AND ANALYSIS

A prospective cohort study will be conducted by recruiting all participants who deliver in a referral centre in South India during a 1-year period after written consent is obtained from them. In addition to clinical information pertaining to their delivery and demographics, details of physical health, mental health socioeconomic status and emotional support will also be collected. Every participant will be followed up physically and/or by telephonic consultation at 3, 9 and 18 months of their postnatal period to reassess their status and that of their babies. As there are several independent and dependent variables requiring multivariate analysis, a sample size of 10 000 is considered adequate. Any unplanned visits to a health facility will be enquired into and documented for analysis.During data analysis, the effect of Caesarean section, high-risk characteristics and gestational age of the baby at delivery on various outcome measures and postnatal status will be evaluated. Interpretation of the large volume of collected data will help frame recommendations to improve postnatal care ETHICS AND DISSEMINATION: The study is approved by the Institutional Review Boards (Research and Ethics Committees) of Christian Medical College, Vellore, Tamil Nadu, India (IRB 12178 date 24 June 2020).Women are provided with a detailed information sheet and written consent is obtained. They are reassured that their care will not be compromised if they do not consent to the study. Data will be available on the clinical trial portal to assist in the dissemination of results after the project is published.

TRIAL REGISTRATION NUMBER

CTRI/2022/03/041343.

A randomized controlled trial comparing combined medical and mechanical method for early mid-trimester abortion (13-20 weeks)

OBJECTIVE

To examine the combined effect of a medical and mechanical method on induction-to-abortion interval (IAI) in women undergoing early mid-trimester abortion (MTA) (13-20 weeks of pregnancy).

METHODS

A randomized controlled trial was conducted among women undergoing MTA. Primary outcome was IAI. At enrollment, 60 women were randomized (group 1: medical method alone [mifepristone 200 mg, then 48 h later vaginal misoprostol 400 μg every 4 h] versus group 2: combined medical and mechanical method [transcervical Foley catheter inflated with 60 ml of normal saline]). Demographic and clinical data were collected at enrollment and abortion.

RESULTS

Women in group 2 had statistically significantly shorter IAI (mean ± standard deviation: 347 ± 130 min vs. 640 ± 242 min, for group 2 and group 1, respectively; P < 0.001). All the women in group 2 had complete abortion within 12 h, compared with 19 (63%) in group 1 (P < 0.001). Median number of doses of vaginal misoprostol (400 μg every 4 h) required in group 1 was 4 (interquartile range [IQR] 3-5) versus 1 (IQR 1-3) in group 2 (P < 0.001). Statistically significantly fewer women required additional oxytocin (group 1 vs. group 2; 4 vs. zero, respectively, P = 0.038). All women in the study had complete abortion. There was no significant difference with respect to maternal complications.

CONCLUSION

A combined medical and mechanical method significantly shortens the IAI (P < 0.001) in women undergoing early MTA (13-20 weeks of pregnancy).

TRIAL REGISTRATION

Clinical Trial Registry of India www.ctri.nic.in CTRI/2020/12/030077 (date; 28-12-2020).

Barriers and facilitators for access and utilization of reproductive and sexual health services among Female Sex Workers in urban and rural Maharashtra, India

Background

The public health interventions among Female Sex Workers (FSWs) have mainly addressed HIV/ STI prevention. The focus of the HIV prevention program on FSWs' Reproductive and Sexual Health (RSH) has been limited, thus, rendering them at a higher risk of unintended pregnancies, delayed pregnancy detection, and utilizing unsafe abortion methods.

Methods

A multistakeholder analysis was performed to study access and use of RSH services among FSWs in urban and rural India. Between January 2016 and June 2019, a qualitative grounded theory approach was used to explore the FSWs' perspectives and experiences about services pertaining to HIV prevention, Antenatal Care (ANC), child delivery, abortion, and pregnancy prevention. Using purposive and convenience sampling, 29 In-Depth Interviews (IDIs), 2 Focus Group Discussions (FGDs) and 22 Key Informant Interviews (KIIs) were conducted with consenting FSWs and indirect stakeholders, respectively. Verbatim translated data was entered in NVivo12 Software and analyzed inductively.

Results

The following themes emerged: (1) Condomless sex, unintended pregnancy, vertical transmission, (2) Signs/ indication used for pregnancy detection causing delay (3) Pregnancy prevention methods used, (4) Pregnancy prevention or AIDS prevention, (5) Legal formalities as a barrier to access RSH, (6) Differential facility preference.

Conclusion

Pregnancy prevention is a greater motivation for condom use than HIV prevention among FSWs. Therefore, there is an emerging need to reallocate public health resources and redesign policies to meet the RSH needs of FSWs, especially for the prevention of unintended pregnancies. FSW-focused Information Education Communication (IEC) strategies for RSH service utilization are essential to reduce the burden of unintended pregnancies. The National HIV Targeted Intervention (TI) program needs to include pregnancy testing services and information to non-barrier contraceptive methods. An ambient policy environment calls for examining the need for male involvement in pregnancy, family planning and abortion decisions.

A study on initiation of postpartum family planning in India based on NFHS-4: does urban poor differ significantly from rural?

OBJECTIVE

To explore the differentials of postpartum contraceptive adoption between rural and urban poor after adjusting for utilization of MCH services and other selected socioeconomic and demographic covariates.

METHODS

The data for this study is taken from the 4th round of NFHS survey conducted in India during 2015-16. The analysis is limited to 125,340 currently married women whose menses had returned at the time of survey. Discrete time complementary log-log multilevel model was applied.  RESULTS: The results clearly indicate that women from rural areas had a lower chance of early initiation of modern spacing methods after having recent birth as compare to that of Urban Poor and Urban non-poor areas. The contributions of several socioeconomic and demographic characteristics that were important for family planning practice were also highlighted in this study.

CONCLUSION

There is an urgent need of designing an intervention that will result in effective delivery of services to achieve the greatest impact. Policy planners must focus on targeted interventions for family planning use in the postpartum period than simply focusing on family planning.

Medical abortion in India - An imperative need for task sharing

Background

Over-the-counter (OTC) sale of medical abortion (MA) inducing drugs is a common practice. Exploring its impact on women's health and the barriers to avail free MA services at hospital by these women is essential to improve upon policy decision.

Methods

A prospective observational study included 112 women following ingestion of MA drugs from nonformal providers. Demography, clinical details, and reasons for not availing free abortion services at hospital were recorded.

Results

Among 112 women, mean age was 28.63 (SD 4.7) years. Seventy one (63.39%) women were from rural region; 70.54% were educated below high school; 44 (39.28%) had prior induced abortion; 62.5% had never used any contraception. Majority (101; 90%) took two drugs (Mifepristone and Misoprostol), 28 (25%) used correct dosage. Drugs were consumed beyond 9 weeks of gestation by 25 (22.4%) women. Abnormal vaginal bleeding was commonest 105 (93.75%) presentation. Haemorrhagic shock was noted in 21 (18.75%) women, while 21 (18.7%) women required blood transfusion. "Easy and quick availability of these drugs OTC" was the commonest statement for not attending hospital.

Conclusion

Easy and quick availability of OTC drugs, distance to hospital were major barriers. Incorrect dosage and lack of gestational age calculation were two most common errors in the risk assessment protocol. Expanding provider base, by training midlevel providers, can overcome these and unmask the full potential of MA to make abortion safer.

Association Between Intimate Partner Violence and Contraceptive Use in India: Exploring the Moderating Role of Husband's Controlling Behaviors

Existing studies show a mixed relationship between intimate partner violence (IPV) and contraceptive use. This study assesses the association between women's exposure to IPV and contraceptive use in India. Furthermore, we aim to determine whether husband's controlling behaviors play a moderating role in the IPV-contraception link. We used nationally representative data from the recent round of the National Family Health Survey (NFHS-4), conducted in 2015-2016. In this study, the use of contraceptives is the outcome variable, categorized into three groups: no/traditional methods, modern methods, and female sterilization. Women's exposure to IPV in the past year is the key exposure of interest. Socio-economic and demographic variables were used as covariates. Multinomial logistic regression models were performed to examine the association between women's exposure to IPV and contraceptive use. Of the total participants (N = 58,891), approximately one in every four women (24.1%) experienced any form of IPV in the past year. Slightly over half (50.8%) reported using either traditional methods of contraception or no contraceptive at all. About 14% of the respondents were using modern methods of contraception and 34.9% had undergone sterilization. After controlling for confounding factors, women who experienced IPV were 8% (95% CI [.87, .99]) less likely to report using modern contraceptives than those who did not face any IPV. Conversely, women who faced IPV were 14% (95% CI [1.09, 1.20]) more likely to undergo sterilization. Furthermore, women who experienced any form of IPV and whose husbands endorse controlling attitudes were 12% (95% CI [.81, .95]) less likely to report using modern contraceptives and 11% (95% CI [1.04, 1.17]) more likely to undergo sterilization. Interventions should be made to prevent violence against women that would increase their ability to choose appropriate contraception methods to avoid unintended pregnancies.

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.

Second-Trimester Medical Abortion with Misoprostol Preceded by Two Sequential Doses of Mifepristone: An Observational Study

Introduction

Based upon the pharmacokinetics of mifepristone, we postulated that repeating a dose after its half-life period may potentiate its abortifacient effect.

Methods

We administered mifepristone (200 mg) on days one and two, and misoprostol on day three (200 or 400 μg, vaginally, six-hourly, upto three doses in 12 h) in 100 women (intervention group). We compared their outcome with that of another 100 women who received the one-dose mifepristone regimen (mifepristone on day one and misoprostol on day three) during the months immediately preceding the study period (historical controls).

Results

The mean age, parity and gestation (18 weeks) were similar in the two groups. On day three (before initiating misoprostol), cervix admitted one finger in significantly more women in the intervention group (36 versus 8% in historical controls; p = 0.001). All women aborted successfully in the two groups. The IAI of the intervention group was significantly shorter than the IAI of historical controls (10.45 vs 13.75 h; p = 0.013), and the misoprostol requirement was also significantly lower (mean 434 vs 500 μg among historical controls, p = 0.04).

Conclusions

Second-trimester medical abortion using two sequential doses of mifepristone followed by misoprostol reduced the IAI and misoprostol requirement without adding any extra days to the existing regimen. Further randomized studies can assess if the 'two-dose' mifepristone regimen is more efficient than the 'one-dose' regimen.

Country-specific estimates of unintended pregnancy and abortion incidence: a global comparative analysis of levels in 2015-2019

Introduction

Internationally comparable estimates of unintended pregnancy and abortion incidence can illuminate disparities in sexual and reproductive health and autonomy. Country-specific estimates are essential to enable international comparison, and to inform country-level policy and programming.

Methods

We developed a Bayesian model which jointly estimated unintended pregnancy and abortion rates using information on contraceptive needs and use, contraceptive method mix, birth rates, the proportions of births from unintended pregnancies and abortion incidence data. Main outcomes were the estimated rates of unintended pregnancy and abortion for 150 countries and territories, reported for the 5-year period 2015–2019, as annual averages per 1000 women aged 15–49 years.

Results

Estimated unintended pregnancy rates ranged from 11 (80% uncertainty interval: 9 to 13) in Montenegro to 145 (131 to 159) in Uganda per 1000 women aged 15–49 years. Between-country heterogeneity was substantial in all Sustainable Development Goal (SDG) regions, but was greatest in sub-Saharan Africa. Estimated abortion rates ranged from 5 (5 to 6) in Singapore to 80 (55 to 113) in Georgia. Variation between country estimates was similar in all SDG regions except for Europe and Northern America, where estimated abortion rates were generally lower.

Conclusion

The estimates reflect variation in the degree to unintended pregnancy and abortion that are experienced in countries throughout the world. This evidence highlights the importance of investing in access to contraception and comprehensive abortion care, including in regions which may have lower rates of unintended pregnancy or abortion, respectively, as countries may differ substantially from regional averages.

Psychometric properties of the Chinese version of the Perinatal Bereavement Care Confidence Scale (C-PBCCS) in nursing practice

BACKGROUND

The Perinatal Bereavement Care Confidence Scale (PBCCS) was designed to evaluate midwives' and nurses' confidence and its psychosocial factors to provide bereavement care in Ireland. However, it is unknown whether this scale is valid and reliable for use with midwives and nurses in China. The aim of this study was to translate the English version into Chinese (C-PBCCS) and determine its validity and reliability in a population of Chinese midwives and nurses.

METHODS

In this cross-sectional observational study, after translating the English version of the PBCCS into Chinese and ensuring the linguistic adequacy and clarity of the language, we evaluated the validity and reliability of the C-PBCCS with Chinese midwives and nurses (n = 608). Participants were recruited using convenience sampling from 10 maternity hospitals in Zhejiang and Jiangsu Provinces. Exploratory factor analysis (EFA) was conducted to determine the construct validity (n = 304). Another sample of 304 midwives and nurses was used for confirmatory factor analysis (CFA) to verify the quality of the factor structures. Cronbach's alpha coefficient and Guttman split-half coefficient were adopted for the evaluation of internal consistency. The STROBE was followed in reporting the results.

RESULTS

The 43-item PBCCS was reduced to 40 items. Bereavement support knowledge (13 items, three factors), Bereavement support skills (eight items, two factors), Self-awareness (eight items, two factors), and Organizational support (11 items, two factors). The CFA suggested that the four scales in the C-PBCCS had acceptable fit indices. The Cronbach's alpha ranged from 0.835-0.901. The Guttman split-half coefficient was between 0.868-0.933.

CONCLUSION

The C-PBCCS was found to be a psychometrically sound measurement tool to evaluate Chinese-speaking midwives' and nurses' confidence and the psychosocial factors that affect their confidence in providing perinatal bereavement care.

Key drivers of fertility levels and differentials in India, at the national, state and population subgroup levels, 2015-2016: An application of Bongaarts' proximate determinants model

OBJECTIVES

The transition to small family size is at an advanced phase in India, with a national TFR of 2.2 in 2015-16. This paper examines the roles of four key determinants of fertility-marriage, contraception, abortion and postpartum infecundability-for India, all 29 states and population subgroups.

METHODS

Data from the most recent available national survey, the National Family Health Survey, conducted in 2015-16, were used. The Bongaarts proximate determinants model was used to quantify the roles of the four key factors that largely determine fertility. Methodological contributions of this analysis are: adaptations of the model to the Indian context; measurement of the role of abortion; and provision of estimates for sub-groups nationally and by state: age, education, residence, wealth status and caste.

RESULTS

Nationally, marriage is the most important determinant of the reduction in fertility from the biological maximum, contributing 36%, followed by contraception and abortion, contributing 24% and 23% respectively, and post-partum infecundability contributed 16%. This national pattern of contributions characterizes most states and subgroups. Abortion makes a larger contribution than contraception among young women and better educated women. Findings suggest that sterility and infertility play a greater than average role in Southern states; marriage practices in some Northeastern states; and male migration for less-educated women. The absence of stronger relationships between the key proximate fertility determinants and geography or socio-economic status suggests that as family size declined, the role of these determinants is increasingly homogenous.

CONCLUSIONS

Findings argue for improvements across all states and subgroups, in provision of contraceptive care and safe abortion services, given the importance of these mechanisms for implementing fertility preferences. In-depth studies are needed to identify policy and program needs that depend on the barriers and vulnerabilities that exist in specific areas and population groups.

Interviewer effects on abortion reporting: a multilevel analysis of household survey responses in Côte d'Ivoire, Nigeria and Rajasthan, India

OBJECTIVES

The analysis aimed to assess the scale of interviewer effects on abortion survey responses, to compare interviewer effects between different question wordings and between direct and indirect approaches, and to identify interviewer and interview characteristics that explain interviewer effects on abortion reporting.

SETTING

2018 Performance Monitoring for Action nationally representative household surveys from Côte d'Ivoire, Nigeria and Rajasthan, India.

PARTICIPANTS

Survey data from 20 016 interviews with reproductive age (15-49) women, selected using multistage stratified cluster sampling. Data from self-administered interviewer surveys and from a sample of health service delivery points that serve the female survey participants were also included.

PRIMARY OUTCOME MEASURES

Outcomes were the respondent's own experience of ever 'removing a pregnancy', their closest confidante's experience of pregnancy removal and the respondent's own experience of period regulation.

RESULTS

Substantial interviewer effects were observed, ranging from 7% in Côte d'Ivoire to 24% in Nigeria for pregnancy removal. Interviewer effects for survey questions that were designed to ask about abortion in a less stigmatising way were either similar to (9%-26% for confidante-reporting) or higher than (17%-32% for a question about period regulation) the pregnancy removal question. Interviewer and interview characteristics associated with abortion reporting included respondent-interviewer familiarity, the language of interview and the interviewer's comfort asking questions about abortion.

CONCLUSION

This study highlights that questions designed to be less stigmatising may increase interviewer effects due to lower comprehension among respondents. Further work is needed to assess question wordings for different contexts. Selecting and training interviewers to ensure comfort asking questions about abortion is important for reproductive health surveys. Challenges for the use of 'insider' interviewers and the management of surveys in countries with high linguistic diversity are also identified.

Fertility intentions and child health in India: Women's use of health services, breastfeeding, and official birth documentation following an unwanted birth

This study examines the relationship between women’s prospective fertility intentions and child health, measured via access to healthcare facilities for children and postpartum maternal behaviors that are indicative of future child health. We analyze two waves of nationally representative data (2005 and 2012) from the India Human Development Survey (IHDS). The analytic sample includes 3,442 non-pregnant, currently married women aged 18–40 in 2005 who participated in both rounds of the IHDS, and had at least one birth between 2005 and 2012. We investigate the influence of women’s prospective fertility intentions on access to benefits from the Integrated Child Development Services (ICDS), indicators of breastfeeding as recommended by the World Health Organization, and official documentation of births via birth certificates or registration. We find that 58 percent of births among women in the sample were labeled as unwanted. We use an adaptation of propensity score matching—the inverse-probability-weighted regression adjustment (IPWRA) estimator—and show that, after accounting for maternal and household characteristics that are known to be associated with maternal and child health, children who resulted from unwanted births were less likely to obtain any benefits or immunizations from the ICDS, to be breastfed within one hour of birth, and to have an official birth certificate. Results from this study have direct policy significance given the evidence that women’s fertility intentions can have negative implications for child health and wellbeing in the short and longer term.

Trends in Abortion Policies in Low- and Middle-Income Countries

The decision to terminate a pregnancy is not one that is taken lightly. The need for an abortion reflects limited sexual autonomy, ineffective or lack of access to contraceptive options, or a health indication. Abortion is protected under human rights law. That notwithstanding, access to abortions continues to be contested in many parts of the world, with vested interests from politically and religiously conservative states, patriarchal societies, and cultural mores, not just within local contexts but also within a broader geopolitical context. Criminalization of a women's choice not to carry a pregnancy is a significant driver of unsafe procedures, and even where abortions are provided legally, the policies remain constrained by the practice or by a lack of coherence. This review outlines the trends in abortion policy in low- and middle-income countries and highlights priority areas to ensure that women are safe and able to exercise their reproductive rights.

The association between intimate partner violence and recent self-managed abortion in India

BACKGROUND

Previous studies have shown that women who experience intimate partner violence have higher rates of unintended pregnancy and abortion—but whether there are differences between the types of abortion care accessed is unknown. Understanding the predictors of self-managed abortion is important for providing risk-mitigating information and resources to those at highest risk for unintended pregnancy and intimate partner violence. With access to information and medication abortion drugs, it is possible that self-managed abortion can be performed safely, increasing reproductive autonomy for women.

OBJECTIVE

The purpose of this study is to evaluate the association between experiencing intimate partner violence and using self-managed abortion.

STUDY DESIGN

This is a cross-sectional analysis of responses of 57,090 married women to the National Family Health Survey-4 conducted across India from 2015 to 2016. The association between the type of intimate partner violence and self-managed abortion was analyzed using multivariable multinomial logistic regression.

RESULTS

Women who have ever experienced physical intimate partner violence were more likely to have any abortion (adjusted relative risk=1.5; 95% confidence interval, 1.2–2.0) and use self-managed abortion (adjusted relative risk=1.7; 95% confidence interval, 1.1–2.6) than women who have not experienced physical intimate partner violence. Women who have ever experienced sexual intimate partner violence may have been more likely to use self-managed abortion, though this association was not statistically significant (adjusted relative risk=2.7; 95% confidence interval, 0.7–10.4).

CONCLUSION

Women who have experienced physical intimate partner violence disproportionately use abortion care, both facility-based and self-managed. Women who have experienced sexual intimate partner violence may also be more likely to use self-managed abortion. Although abortion is legal, self-managed abortion is commonly occurring in India. Self-managed abortion represents an additional choice and enhances reproductive autonomy in settings where abortion is legal. The implementation of risk-mitigation resources and policies regarding self-managed abortion would provide protection and enhanced autonomy to susceptible groups across India.

Differential treatment in the provision of medication abortion at pharmacies in Uttar Pradesh, India

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

Association between adverse pregnancy outcomes and preceding risk factors: a cross-sectional study from Nashik District, India

Background

The preconception phase of women’s life cycle is critical but comparatively ignored. The presence of health risks is judged as hazardous to the wellbeing of women and their offspring. This study aimed to estimate the prevalence of various pregnancy outcomes and assess the association between certain risk factors and adverse outcomes.

Methods

As a part of a preconception care intervention project, a baseline survey was conducted in four blocks of Nashik District, India. In this population-based cross-sectional analytical study, we compared cases in the study group (randomly selected one tribal and one non-tribal block) with those of the control group (one tribal and one non-tribal block). A comparison was also made between the tribal and non-tribal blocks in each group. All women who had a pregnancy outcome in the preceding 12 months (01 April 2017 to 31 March 2018) were interviewed. Trained Accredited Social Health Activists conducted the survey under the direct supervision of Auxiliary Nurse Midwives and Medical Officers. Multivariate analysis was carried out to find the adjusted prevalence ratio of having a particular adverse outcome because of the prespecified potential risk factors.

Results

A total of 9307 women participated in the study. The prevalence of adverse pregnancy outcomes was as follows: abortion in 4.1%, stillbirth in 1.7%, preterm birth in 4.1%, low birth weight in 13.2%, and congenital physical defect in 2.8%. Prevalence of parental consanguinity, pre-existing maternal illness at conception, heavy work during the last six months of pregnancy, tobacco consumption, alcohol consumption, direct exposure to pesticides and domestic violence during pregnancy was 18.5, 2.2, 18.7, 5.6, 0.5, 2.3, and 0.8% respectively. Risk factors associated with abortion included pre-existing illness and heavy work in the last six months of the pregnancy. Consanguinity, tobacco consumption during pregnancy and pre-existing illness were identified as risk factors for stillbirth. Significant risk factors of low birth weight were heavy work in the last six months of pregnancy, pre-existing illness and residence in a tribal area.

Conclusion

There is a need to emphasize on maternal behaviour, including tobacco consumption, and heavy work during pregnancy, as well as on parental consanguinity and pre-existing maternal illnesses, in order to achieve the best possible pregnancy outcomes.

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.

Association between the place of abortion and post-abortion contraceptive adoption and continuation: the case of India

The unmet need for contraception is documented as a significant determinant of unintended pregnancies and high number of induced abortions. The period immediately after an abortion is recognised as a unique opportunity to offer contraceptive services. This paper explores the association between place of abortion and women's post-abortion contraceptive behaviour. The reproductive calendar data from the National Family Health Survey (NFHS-4) (2015–16) was used for this study. Multinomial logistic regression models were used to understand factors associated with post-abortion method choices. Single decrement life-tables were built to examine rates of contraceptive discontinuation and proportional hazard models were employed to examine probability and correlates of method discontinuation. About 20% of women who underwent an abortion adopted a contraceptive method by the end of one month following an abortion. The decision to choose methods like sterilisation or intrauterine contraceptive devices (IUCDs) was associated with the place of abortion, past contraceptive behaviour, number and sex of surviving children at the time of abortion, mass media exposure, and time of the abortion. Compared to women who underwent an abortion at private health facilities, women who sought abortion at public health facilities were more likely to choose permanent methods or IUCDs. Furthermore, women who opted for an IUCD were less likely to discontinue the method compared to those using short-acting modern methods. The lack of post-abortion contraceptive choices for women is evident in the low uptake of post-abortion contraceptives in private facilities and the predominant promotion of permanent methods and IUCDs in public health facilities.

Course and outcomes of pregnancy in women treated for acromegaly: Discerning a contemporary cohort

OBJECTIVE

To analyze pregnancy course and outcomes in women treated for acromegaly and compare outcomes based on disease activity at the time of conception.

DESIGN

Retrospective study.

PATIENTS

Women with acromegaly diagnosed prior to or during pregnancy from 2010 to 2019, representing cases (14 pregnancies in 12 cases), were later stratified based on active (n = 5) or controlled disease (n = 9) at time of conception. Female acromegalic patients over the same period constituted the 'acromegaly cohort' (AC) (n = 75).

RESULTS

All cases had macroadenomas with nadir GH of 15.06 ng/ml (IQR 9-30), IGF-I index of 3.04 (1.96-3.82), for which they had undergone pituitary surgery; except two patients diagnosed during pregnancy, who received pharmacotherapy followed by surgery 4 months postpartum. Adjuvant pharmacotherapy was required in 71.4% patients and radiotherapy in 35.7%. Pregnancy occurred at a median of 2 (0.8-5.1) years after surgery and 21.4% required assisted reproduction. All had term delivery with normal APGAR except one case with gestational hypertension, who delivered a preterm baby. None had congenital malformations. Despite higher baseline IGF-I, GH and tumor volume in those with pre-conceptional active acromegaly, materno-fetal outcomes were not different from those with controlled disease (p > 0.05). Similar or greater proportion of cases had normal GH and no residual tumor postpartum, even in those with pre-conceptional active acromegaly.

CONCLUSION

The current study showed conducive outcomes of gestation in women treated for acromegaly and no higher rates of pregnancy parameters or complications than non-acromegaly pregnancies in the same population. Active acromegaly does not seem to have an adverse bearing on outcomes.