The incidence of abortion and unintended pregnancy in India, 2015

Background

Reliable information on the incidence of induced abortion in India is lacking. Official statistics and national surveys provide incomplete coverage. Since the early 2000s, medication abortion has become increasingly available, improving the way women obtain abortions. The aim of this study was to estimate the national incidence of abortion and unintended pregnancy for 2015.

Methods

National abortion incidence was estimated through three separate components: abortions (medication and surgical) in facilities (including private sector, public sector, and non-governmental organisations [NGOs]); medication abortions outside facilities; and abortions outside of facilities and with methods other than medication abortion. Facility-based abortions were estimated from the 2015 Health Facilities Survey of 4001 public and private health facilities in six Indian states (Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu, and Uttar Pradesh) and from NGO clinic data. National medication abortion drug sales and distribution data were obtained from IMS Health and six principal NGOs (DKT International, Marie Stopes International, Population Services International, World Health Partners, Parivar Seva Santha, and Janani). We estimated the total number of abortions that are not medication abortions and are not obtained in a health facility setting through an indirect technique based on findings from community-based study findings in two states in 2009, with adjustments to account for the rapid increase in use of medication abortion since 2009. The total number of women of reproductive age and livebirth data were obtained from UN population data, and the proportion of births from unplanned pregnancies and data on contraceptive use and need were obtained from the 2015–16 National Family Health Survey-4.

Findings

We estimate that 15·6 million abortions (14·1 million–17·3 million) occurred in India in 2015. The abortion rate was 47·0 abortions (42·2–52·1) per 1000 women aged 15–49 years. 3·4 million abortions (22%) were obtained in health facilities, 11·5 million (73%) abortions were medication abortions done outside of health facilities, and 0·8 million (5%) abortions were done outside of health facilities using methods other than medication abortion. Overall, 12·7 million (81%) abortions were medication abortions, 2·2 million (14%) abortions were surgical, and 0·8 million (5%) abortions were done through other methods that were probably unsafe. We estimated 48·1 million pregnancies, a rate of 144·7 pregnancies per 1000 women aged 15–49 years, and a rate of 70·1 unintended pregnancies per 1000 women aged 15–49 years. Abortions accounted for one third of all pregnancies, and nearly half of pregnancies were unintended.

Interpretation

Health facilities can have a greater role in abortion service provision and provide quality care, including post-abortion contraception. Interventions are needed to expand access to abortion services through better equipping existing facilities, ensuring adequate and continuous supplies of medication abortion drugs, and by increasing the number of trained providers. In view of how many women rely on self-administration of medication abortion drugs, interventions are needed to provide women with accurate information on these drugs and follow-up care when needed. Research is needed to test interventions that improve knowledge and practice in providing medication abortion, and the Indian Government at the national and state level needs to prioritise improving policies and practice to increase access to comprehensive abortion care and quality contraceptive services that prevent unintended pregnancy.

Funding

Government of UK Department for International Development (until 2015), the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, and the Ford Foundation.

The Incidence of Menstrual Regulation Procedures and Abortion in Bangladesh, 2014

CONTEXT

Menstrual regulation (MR) has been part of the Bangladesh family planning program since 1979. However, clandestine abortion remains a serious health problem in Bangladesh, and anecdotal reports indicate that clandestine use of misoprostol has increased since the most recent estimates (for 2010). Because of this, it is important to assess changes in the use of MR services and the incidence of clandestine abortion since 2010.

METHODS

A survey of a nationally representative sample of 829 health facilities that provide MR or postabortion care services and a survey of 322 professionals knowledgeable about these services were conducted in 2014. Direct and indirect methods were applied to calculate the incidence of MR and induced abortion.

RESULTS

In 2014, an estimated 1,194,000 induced abortions were performed in Bangladesh (29 per 1,000 women aged 15-49), and 257,000 women were treated for complications of such abortions (a rate of 6 per 1,000 women aged 15-49). Among women with complications, the proportion presenting with hemorrhage increased significantly, from 27% to 48%. An estimated 430,000 MR procedures (using MVA or medication) were performed in health facilities nationwide, a decline of about 40% in the MR rate-from 17 to 10 per 1,000 women aged 15-49-from 2010 to 2014.

CONCLUSIONS

Given declines in MR provision, more attention needs to be paid to building capacity, including hiring and training more providers of MR. Harm-reduction approaches should be pursued to increase the safety of clandestine use of misoprostol in Bangladesh.

The cost of post-abortion care in developing countries: a comparative analysis of four studies

Over the last five years, comprehensive national surveys of the cost of post-abortion care (PAC) to national health systems have been undertaken in Ethiopia, Uganda, Rwanda and Colombia using a specially developed costing methodology—the Post-abortion Care Costing Methodology (PACCM). The objective of this study is to expand the research findings of these four studies, making use of their extensive datasets. These studies offer the most complete and consistent estimates of the cost of PAC to date, and comparing their findings not only provides generalizable implications for health policies and programs, but also allows an assessment of the PACCM methodology. We find that the labor cost component varies widely: in Ethiopia and Colombia doctors spend about 30–60% more time with PAC patients than do nurses; in Uganda and Rwanda an opposite pattern is found. Labor costs range from I$42.80 in Uganda to I$301.30 in Colombia. The cost of drugs and supplies does not vary greatly, ranging from I$79 in Colombia to I$115 in Rwanda. Capital and overhead costs are substantial amounting to 52–68% of total PAC costs. Total costs per PAC case vary from I$334 in Rwanda to I$972 in Colombia. The financial burden of PAC is considerable: the expense of treating each PAC case is equivalent to around 35% of annual per capita income in Uganda, 29% in Rwanda and 11% in Colombia. Providing modern methods of contraception to women with an unmet need would cost just a fraction of the average expenditure on PAC: one year of modern contraceptive services and supplies cost only 3–12% of the average cost of treating a PAC patient.

Cost-effectiveness of two interventions for the prevention of postpartum hemorrhage in Senegal

OBJECTIVE

To compare, at the community level, the cost-effectiveness of oxytocin and misoprostol for the prevention of postpartum hemorrhage (PPH).

METHODS

The present cost-effectiveness study used data collected during a randomized trial that compared the prophylactic effectiveness of misoprostol and oxytocin for the prevention of PPH in a rural setting in Senegal between June 6 and September 21 2013. The two interventions were compared, with referral to a higher level facility owing to PPH being the outcome measure. The costs and effects were calculated for two hypothetical cohorts of patients delivering during a 1-year period, with each cohort receiving one intervention. A comparison with a third hypothetical cohort receiving the current standard of care was included. A sensitivity analysis was performed to estimate the impact of variations in model assumptions.

RESULTS

The cost per PPH referral averted was US$ 38.96 for misoprostol and US$ 119.15 for oxytocin. In all the scenarios modeled the misoprostol intervention dominated, except in the worst-case scenario, where the oxytocin intervention demonstrated slightly better cost-effectiveness.

CONCLUSION

The use of misoprostol for PPH prophylaxis could be cost effective and improve maternal outcomes in low-income settings.

Documenting the individual- and household-level cost of unsafe abortion in Uganda

CONTEXT

Although Uganda has a restrictive abortion law, illegal abortions performed under dangerous conditions are common. Data are lacking, however, on the economic impact of postabortion complications on women and their households.

METHODS

Data from a 2011-2012 survey of 1,338 women who received postabortion care at 27 Ugandan health facilities were used to assess the economic consequences of unsafe abortion and subsequent treatment. Information was obtained on treatment costs and on the impact of abortion complications on children in the household, on the productivity of the respondent and other household members, and on changes in their economic circumstances.

RESULTS

Most women reported that their unsafe abortion had had one or more adverse effects, including loss of productivity (73%), negative consequences for their children (60%) and deterioration in economic circumstances (34%). Women who had spent one or more nights in a facility receiving postabortion care were more likely than those who had not needed an overnight stay to experience these three consequences (odds ratios, 1.6-2.8), and women who had incurred higher postabortion care expenses were more likely than those with lower expenses to report deterioration in economic circumstances (1.6). Wealthier women were less likely than the poorest women to report that their children had suffered negative consequences (0.4-0.5).

CONCLUSIONS

The impact of complications of unsafe abortion and the expense of treating them are substantial for Ugandan women and their households. Strategies to reduce the number of unsafe procedures, such as by expanding access to contraceptives to prevent unintended pregnancies, are urgently needed.

The health system cost of post-abortion care in Rwanda

Based on research conducted in 2012, we estimate the cost to the Rwandan health-care system of providing post-abortion care (PAC) due to unsafe abortions, a subject of policy importance not studied before at the national level. Thirty-nine public and private health facilities representing three levels of health care were randomly selected for data collection from key care providers and administrators for all five regions. Using an ingredients approach to costing, data were gathered on drugs, supplies, material, personnel time and hospitalization. Additionally, direct non-medical costs such as overhead and capital costs were also measured. We found that the average annual PAC cost per client, across five types of abortion complications, was $93. The total cost of PAC nationally was estimated to be $1.7 million per year, 49% of which was expended on direct non-medical costs. Satisfying all demands for PAC would raise the national cost to $2.5 million per year. PAC comprises a significant share of total expenditure in reproductive health in Rwanda. Investing more resources in provision of contraceptive services to prevent unwanted or mistimed pregnancies would likely reduce health systems costs.

Benefits of meeting the contraceptive needs of Cameroonian women

(1) In 2013, an estimated 40% of pregnancies in Cameroon were unintended. (2) More than six in 10 women who want to avoid pregnancy either do not practice contraception or use a relatively ineffective traditional method. These women can be said to have an unmet need for modern contraception. (3) Meeting just half of this unmet need would prevent 187,000 unplanned pregnancies each year, resulting in 65,000 fewer unsafe abortions and 600 fewer maternal deaths annually. (4) If all unmet need for modern methods were satisfied, maternal mortality would drop by more than one-fifth, and unintended births and unsafe abortions would decline by 75%. (5) Investing in contraceptive commodities and services to fulfill all unmet need among women who want to avoid pregnancy would result in a net annual savings of US$5.4 million (2.7 billion CFA francs) over what would otherwise be spent on medical costs associated with unintended pregnancies and their consequences. (6) Expanding contraceptive services confers substantial benefits to women, their families and society. All stakeholders, including the Cameroon government and the private sector, should increase their investment in modern contraceptive services.

Benefits of Meeting the Contraceptive Needs of Malawian Women

(1) In 2013, an estimated 54% of pregnancies in Malawi were unintended. (2) More than four in 10 women have an unmet need for modern contraception—that is, they want to avoid pregnancy, but either are not practicing contraception or are using a relatively ineffective traditional method. (3) Meeting just half of this unmet need would prevent 213,000 unintended pregnancies annually, which would result in 34,000 fewer unsafe abortions and 800 fewer maternal deaths each year. (4) If all unmet need for modern contraception were met, maternal mortality would decline by more than two-fifths, and unintended births and unsafe abortions would drop by 87%. (5) Investing in contraceptive commodities and services to fulfill all unmet need for modern contraception would result in a net annual savings of US$11 million (4.1 billion Malawi kwachas) over what would otherwise be spent on medical costs associated with unintended pregnancies and their consequences. (6) Expanding contraceptive services confers substantial benefits to women, their families and society. All stakeholders—including the Malawi government and the private sector—should increase their investment in modern contraceptive services.

The incidence of menstrual regulation procedures and abortion in Bangladesh, 2010

CONTEXT

Bangladesh is unique in including menstrual regulation (MR) services as part of the government family planning program, despite having a highly restrictive abortion law. The only national estimates of MR and abortion incidence are from a 1995 study, and updated information is needed to inform policies and programs regarding the provision of MR and related reproductive health services.

METHODS

Surveys of a nationally representative sample of 670 health facilities that provide MR and postabortion care services and of 151 knowledgeable professionals were conducted in 2010, and MR service statistics of nongovernmental organizations were compiled. Indirect estimation techniques were applied to calculate the incidence and rates of MR and induced abortion.

RESULTS

In 2010, an estimated 647,000 induced abortions were performed in Bangladesh, and 231,400 women were treated for complications of such abortions. Furthermore, an estimated 653,000 MR procedures were performed at facilities nationwide. However, an estimated 26% of all women seeking an MR at facilities were turned away, and about one in 10 of those who had an MR were treated for complications. Nationally, the annual abortion rate was 18.2 per 1,000 women aged 15-44, and the MR rate was 18.3 per 1,000 women.

CONCLUSIONS

The incidence of induced abortion is the same as that of MR, which suggests considerable unsatisfied demand for the latter service. Furthermore, the high rates of complications from MRs highlight the need to improve the quality of clinical services. Increased access to contraceptives and MR services would help reduce rates of unplanned pregnancy and unsafe abortion.

The health system cost of postabortion care in Ethiopia

To address the knowledge gap that exists in costing unsafe abortion in Ethiopia, estimates were derived of the cost to the health system of providing postabortion care (PAC), based on research conducted in 2008. Fourteen public and private health facilities were selected, representing 3 levels of health care. Cost information on drugs, supplies, material, personnel time, and out-of-pocket expenses was collected using an ingredients approach. Sensitivity analysis was used to determine the most likely range of costs. The average direct cost per client, across 5 types of abortion complications, was US $36.21. The annual direct cost nationally ranged from US $6.5 to US $8.9 million. Including indirect costs and satisfying all demand increased the annual national cost to US $47 million. PAC consumes a large portion of the total expenditure in reproductive health in Ethiopia. Investing more resources in family planning programs to prevent unwanted pregnancies would be cost-beneficial to the health system.

The health system cost of post-abortion care in Uganda

This article presents estimates based on the research conducted in 2010 of the cost to the Ugandan health system of providing post-abortion care (PAC), filling a gap in knowledge of the cost of unsafe abortion. Thirty-nine public and private health facilities were sampled representing three levels of health care, and data were collected on drugs, supplies, material, personnel time and out-of-pocket expenses. In addition, direct non-medical costs in the form of overhead and capital costs were also measured. Our results show that the average annual PAC cost per client, across five types of abortion complications, was $131. The total cost of PAC nationally, including direct non-medical costs, was estimated to be $13.9 million per year. Satisfying all demand for PAC would raise the national cost to $20.8 million per year. This shows that PAC consumes a substantial portion of the total expenditure in reproductive health in Uganda. Investing more resources in family planning programmes to prevent unwanted and mistimed pregnancies would help reduce health systems costs.

Benefits of meeting women's contraceptive needs in Burkina Faso

Many women and couples in Burkina Faso do not have the knowledge, means or support they need to protect their reproductive health and to have the number of children they desire. Consequently, many women have more children than they want or can care for. Others turn to induced abortion, which is overwhelmingly clandestine and potentially unsafe. By helping women and couples plan their families and have healthy babies, good reproductive health care--including sufficient access to contraceptive services--contributes directly to attaining three Millennium Development Goals (MDGs): reducing child mortality, improving maternal health, and combating HIV/AIDS. Improving contraceptive services may also make meeting other MDGs--such as achieving universal primary education, reducing endemic poverty and promoting women's empowerment and equality--easier and more affordable. This In Brief aims to chart a course toward better health for Burkinabe women and their families by highlighting the health benefits and cost savings that would result from improved contraceptive services. Building on prior work and using national data to provide estimates for 2009 (see box), it describes current patterns of contraceptive use and two hypothetical scenarios of increased use to quantify the net benefits to women and society that would result from helping women avoid pregnancies they do not want. We focus on the disability and deaths that would be averted and the financial resources that would be saved through preventing unintended pregnancy.

Benefits of meeting the contraceptive needs of Ethiopian women

The ability to practice contraception is essential to protecting Ethiopian women's health and enables them to plan the size and timing of their families. Yet low levels of contraceptive use have led to high levels of unintended pregnancy in Ethiopia, a problem for which women and society pay dearly-in women's lives, family well-being and public funds.

Estimates of health care system costs of unsafe abortion in Africa and Latin America

CONTEXT

Each year, 19 million unsafe abortions occur in developing countries, and an estimated five million women are treated for the resulting serious medical complications. Meanwhile, the economic impact of postabortion care on health care systems in Africa and Latin America is poorly understood (data for Asia are lacking).

METHODS

Two main approaches were used to estimate the cost of postabortion care: calculating the average cost of care per patient, as represented in 20 empirical studies, and analyzing treatment costs using the WHO Mother-Baby Package model, which enumerates the costs of specific components of treatment related to postabortion complications. The average cost estimates from each approach were multiplied by the annual number of cases of hospitalization for postabortion care to generate regional cost estimates. Three methods (low severity, weighted severity, and inclusion of overhead and capital costs) were used to generate a range of per-patient and regional cost estimates.

RESULTS

The average per-patient cost of postabortion care ranged from $83 in Africa to $94 in Latin America (2006 US$); estimates based on the WHO Mother-Baby Package model were between $57 and $109 per case. The health system costs of postabortion care in the two regions combined ranged from $159 million to $333 million per year. The average estimates from the two approaches were similar: $280 million and $274 million, respectively.

CONCLUSIONS

The costs of treating medical complications from unsafe abortion constitute a significant financial burden on public health care systems in the developing world, and postabortion complications are a significant cause of maternal morbidity.

Benefits of meeting the contraceptive needs of Ugandan women

This brief describes current patterns of contraceptive use in Uganda and documents the high costs associated with persistently high unmet need for modern contraceptives. Building on prior work and using national data sets to project estimates for 2008, we outline the net benefits to women and society of averting unintended pregnancies with current levels of use and under two scenarios of increased investment in modern contraception. Although enabling women to meet their childbearing preferences leads to an array of benefits--such as enhancing women's ability to go to school, enter the workforce and participate politically--we focus exclusively on the health and monetary savings from averting unintended pregnancy.

A rejoinder to S. K. Datta and J. B. Nugent

Abstract Extract The question of old-age security as a motivation for fertility in less-developed rural areas can be put in clearer perspective by pausing to consider the changing roles of land and offspring under the influence of fundamental demographic upheaval. Under the pre-transition regime, one generation approximately replaced the preceding one, particularly once unused but usable land became scarce and the possibility of expanding farm operations became remote. Judging from the settlement patterns and the history of the Maharashtrian study area, such a circumstance probably obtained long before the secular drop in mortality began. During this period, a single son, typically, would survive to adulthood, gradually assuming control of the father's land (or the father's trade, among non-agriculturalists) and, if the father lived long enough, would eventually be a source of security in the father's old age. It is not inappropriate to mention that this generational cycle no doubt fostered a strong urge to leave the family land to a son, so that a sonless farmer would keenly feel a lack of fulfilment. In fact, responses to certain survey questions suggest that ancestral land and male progeny are still somehow connected, according to the way village men think, to their sense of immortality. It would be hard, consequently, to separate old-age security, the idea of 'continuing a lineage', and the sense of immortality conferred by owning land into distinct motives for conceiving children.

Family type and fertility in rural India: a critical analysis

This paper, based on data from two independent but concurrent studies, seeks to show that the explanation for the inconclusive results concerning fertility and family type in India lies in the failure of previous researchers to take account of an important intervening variable, the family life cycle. Fertility levels are examined in nuclear and joint families in a village in Western India and changes in relationships at different stages in the family cycle are considered. The most important conclusion is that aggregate level observations which indicate that fertility varies according to family type are misleading. When other relevant factors such as age or stage in the family life cycle are controlled, there is little evidence of any intrinsic connection between fertility and family type.

Misreporting in rural fertility data: an analysis of husband-wife disagreement

Two independent, concurrent demographic surveys in rural India, one male, the other female, were used to examine misreporting of ever-born children among 223 couples common to both samples. Husband-wife disagreements were checked in detail and characteristics of the errors and of the misreporters themselves were analysed. ‘Forgetting’ of dead children was the main cause of mistaken reporting. Another type of error was found to be sex-related: men, but not women, confused fetal deaths with live births. Of the various correlates of male misreporting tested, only age appeared to be a determining factor. On the other hand, traditional attitudes and overall response reliability were more important than age in explaining female errors. No significant relationships between faulty reporting and socio-economic status or family size were established. Various suggestions are made for minimizing fertility misreporting in surveys of rural, illiterate populations.