ABORTION OPTIONS FOR RURAL WOMEN :CASE STUDIES FROM THE VILLAGES OF

BOKARO DISTRICT, JHARKHAND

Lindsay Barnes

Abortion Assessment Project - India

TABLE OF CONTENTS

PREFACE vABSTRACT viiGLOSSARY OF TERMS AND ACRONYMS viiiI. BACKGROUND 1II. METHODOLOGY 2III. SELECTION METHOD 2IV. PROFILE OF THE WOMEN 4V. PREVENTING UNWANTED PREGNANCIES:

WOMEN’S EXPERIENCE OF CONTRACEPTION 5A. CONTRACEPTION USE PRIOR TO ABORTION

B. CONTRACEPTION USE FOLLOWING ABORTION

VI. THE ABORTION OPTIONS AVAILABLE:SERVICE PROVIDERS AND TECHNIQUES 7A. QUALIFIED MEDICAL PRACTITIONERS (PRIVATE/GOVERNMENT)B. UNQUALIFIED MEDICAL PRACTITIONERS

C. FEMALE HERBAL PRACTITIONERS

VII. DEALING WITH UNWANTED PREGNANCIES :RURAL WOMEN’S EXPERIENCES OF ABORTION 10A. DECISION-MAKING AND ABORTION

B. THE ABORTION EXPERIENCE

C. COST AND ABORTION CARE

D. ACCESSIBILITY AND ABORTION

E. IMPACT ON WOMEN’S HEALTH

VIII. CASES OF ABORTION-RELATED DEATHSNOT INCLUDED IN THIS STUDY 14

IX. DISCUSSION 15X. APPENDIX

1. APPENDIX1 ABORTION ASSESSMENT SCHEDULE 17

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Ravi Duggal22nd September 2003 Coordinator, CEHAT

Abortions have been around forever. Butat different points of time in history it hasreceived attention for differing reasons, somein support of it, but often against it. Abortionis primarily a health concern of women butit is increasingly being governed by patriar-chal interests which more often than notcurb the freedom of women to seek abortionas a right.

In present times with the entire focusof women’s health being on her reproduction,infact preventing or terminating it, abortionpractice becomes a critical issue. Given theofficial perspective of understanding abortionwithin the context of contraception, it is im-portant to review abortion and abortion prac-tice in India.

The Abortion Assessment Project India(AAP-I) has evolved precisely with this con-cern and a wide range of studies are beingundertaken by a number of institutions andresearchers across the length and breadthof the country. The project has five compo-nents:I. Overview paper on policy related issues,

series of working papers based on exist-ing data / research and workshops to poolexisting knowledge and information inorder to feed into this project.

II. Multicentric facility survey in six statesfocusing on the numerous dimensionsof provision of abortion services in thepublic and private sectors

III. Eight qualitative studies on specific is-sues to compliment the multicentricstudies. These would attempt to under-

stand the abortion and related issuesfrom the women’s perspective.

IV. Household studies to estimate incidenceof abortion in two states in India.

V. Dissemination of information and litera-ture widely and development of an advo-cacy strategyThis five pronged approach will, hope-

fully, capture the complex situation as it isobtained on the ground and also give policymakers, administrators and medical profes-sionals’ valuable insights into abortion careand what are the areas for public policy in-terventions and advocacy.

The present publication is the second inthe AAP-I series of working papers. LindsayBarnes has conducted a survey in Bokarodistrict in newly created Jharkhand stateand presented first hand information on safeand legal abortion services scenario in thearea.

We thanks Sunanda Bhattacharjea forassisting in the language editing of this pub-lication and Mr. Ravindra Thipse, Ms. MurielCarvalho and Margaret Rodrigues for timelypublication of this entire series.

This working paper series has been sup-ported from project grants from RockefellerFoundation, USA and The Ford Foundation,New Delhi. We acknowledge this supportgratefully.

We look forward to comments and feed-back which may be sent to cehat@vsnl.comInformation on this project can be obtainedby writing to us or accessing it from thewebsite www.cehat.org

PREFACE

This study aimed to document poor, ru-ral women’s experience of abortion in a back-ward part of the Bokaro district inJharkhand. Twenty five women who had ex-perienced abortions during the previous twoyears were selected, and interviewed utiliz-ing a semi-structured questionnaire. A smallnumber of service providers were also inter-viewed.

All the women were married, and mosthad accessed abortions after reaching theiroptimum family size. The average age of thewomen was 31.2 years. Only two women inthe study were literate, and were mostlytribal, Muslim, backward and scheduledcaste.

The study highlighted the total lack ofaccessible, affordable and safe abortion ser-vices. Only three

women experienced a complication-free,safe abortion from a single, qualified serviceprovider. Fifteen women had to access carefrom more than one provider, since the com-plications that arose could not, normally, bemanaged by the same provider. Women of-

ABSTRACT

ten accessed different methods of abortion,which added to cost and risk.

The crucial role of the unqualified ruralmedical practitioners was noted: as provid-ers of abortion services, and as agents forservice providers. These private, unqualifiedpractitioners were found to have a negativeimpact on women’s health, and gain finan-cially from the promotion of abortion. Nonehad provided contraceptive counseling,warned women of the dangers of repeatedabortion or the risks of infection.

None of the women in the study hadavailed government services for abortioncare, or for the management of abortion-re-lated complications. Apart from the fourwomen who accessed abortions from the hos-pital of Bokaro Steel Plant (since they agreedto undergo the compulsory sterilization) allwomen had accessed illegal abortion ser-vices. The study shows that in a systemdominated by private practitioners, abortioncare becomes a lucrative source of profit, andwomen’s overall health and well-being is alow priority.

vii

GLOSSARY OF TERMS AND ACRONYMS

BGH Bokaro General Hospital

D&C Dilation and Curettage

D&E Dilation and Evacuation

DGO Diploma in Gynaecology & Obstetrics

FHP Female Herbal Practitioner

IUD Intrauterine Device

MMS Mahila Mandal Samiti

MMWSHG Mahila Mandal Women’s Self Help Groups

MTP Medical termination of Pregnancy

OCPs Oral Contraceptive Pills

RCH Reproductive & Child Health

RMP Rural Medical Practitioner

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The aim of this study is to documentpoor, rural women’s experience of abor-tion in a backward part of the Bokarodistrict in Jharkhand. We hope to explorewhat women do when faced with an un-wanted pregnancy, and what obstacles theyface in accessing safe and accessibleabortion.

I. BACKGROUNDAlthough the medical termination of

pregnancy (MTP) has been legalised for al-most 30 years and abortion care is suppos-edly provided for in the Government’s ‘Re-productive and Child Health’ (RCH) program,safe and legal abortion remains inacces-sible for the vast majority of rural women inJharkhand. Poor, village women continueto risk their lives and health in seekingtermination of an unwanted pregnancy. Thecollapse of the government’s health system,the non-availability of birth spacing meth-ods in spite of the priority given to the pro-motion of family planning, has further ex-acerbated this problem.

Bokaro district, in the newly createdJharkhand State, is typical of the sort ofdevelopment that is taking place. Althoughthe state has a well-equipped hospital, it isavailable only for the employees of the steelplant. Safe and legal abortion services areavailable in the hospital, but the servicecharges prohibit the vast majority of poorwomen from accessing the service.

If women agree to undergo tubectomies,abortion services at the Bokaro General

ABORTION OPTIONS FOR RURAL WOMEN : CASE STUDIES FROM VILLAGES OF

BOKARO DISTRICT, JHARKHAND

Hospital (BGH) are provided free of cost.However, the bureaucratic obstacles to getadmission, the number of visits needed, theamount of time involved, have all served todeter many women from accessing this fa-cility. Besides, during the busy ‘family plan-ning campaign season’, from November toMarch, this service is in practice withdrawn.Women with unwanted pregnancies arerefused admission.

The government health centres in thedistrict do not provide regular birth spacingservices, delivery care, let alone abortionservices. The government’s referral hospi-tal does not have the facilities to perform amajor surgery that may be needed duringobstetric emergencies or as a result of abor-tion complications (such as perforation ofthe uterus, which may necessitate a hys-terectomy). The Civil Surgeon informed usthat no government doctor in the district isqualified to provide abortion services.

Faced with an unwanted pregnancy, poorvillage women have the following ‘options’:l To continue with the pregnancyl Agree to undergo a tubectomy and try to

get admission into Bokaro General Hos-pital

l Access (illegal) abortion from a quali-fied, private (MBBS/ MBBS & Diploma inGynaecology & Obstetrics[DGO]) doctorin Bokaro

l Access (illegal and unsafe) abortion carefrom an unqualified allopathic medical

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practitioner (RMP/ unqualified ‘nurse’))in the city or at village level

l Access (illegal and unsafe) abortion carefrom a female herbal practitioner (FHP)A cloud of illegality surrounds abortion

care, with almost all medical practitionersin the district involved in providing illegalservices. Most village women are ignorantof the fact that the termination of pregnancyis not illegal. This has all resulted in thedetriment of their health, and added to cost.

There are few studies of women’s actualexperience of illegal abortion, which is themost common form of service available tothe vast majority of women in India. In thevillages of Bokaro district, there is no sharpdividing line between the varieties of abor-tion services accessed by poor women. Thepopular perception of the ‘modern’, clean andsafe medical abortion techniques practicedby qualified doctors on the one hand and the‘traditional’ unsafe practices of village mid-wives on the other, is much more complicatedin reality. This study aims to unearth the sortof abortion service women are actually avail-ing, and what the obstacles they face actuallyare in accessing quality care.

II. METHODOLOGYThe author is currently involved in or-

ganising women’s reproductive health ser-vices through a federation of over 200 selfhelp groups, with a membership of around5000 women, in the Chas and Chandankiariblocks of Bokaro district. This federation,the ‘Mahila Mandal Samiti’ (MMS), has helpedset up a women’s health centre, in whicha weekly reproductive health clinic is orga-nised, attended by a qualified gynaecologist.Many members of the groups access healthservices from this centre, and often comefor advice regarding unwanted pregnancies,for help in accessing abortion and tubal li-gation operations from Bokaro General Hos-pital, and with complications from unsafeabortions. The health centre does not pro-vide abortion services, and can only refer

women. Few women, however, access thesafe abortion care as advised, and most resortto unsafe practitioners or continue with thepregnancy.

At the time of the interview, December2002, the need for safe abortion serviceswas very much on the agenda of the ‘MahilaMandal Samiti’. During the previous yearthree members of the women’s groups haddied due to unsafe abortions. Two of thesewomen had approached the women’s healthcentre for help in terminating their early,unwanted pregnancies. They were referredto Bokaro General Hospital (if they wereready to accept sterilisation) or to a private,qualified medical practitioner. Neither fol-lowed these routes. Their deaths were widelydiscussed in the women’s groups, leading toa questioning of referral practices and thedemand for easier, safer, accessible abor-tion services. The women’s health centrehopes to be able to provide safe and earlyabortion in the near future.

This study coincided with this increasedconcern amongst members for abortion ser-vices, and most women were willing to par-ticipate in the interviews. The author alsofelt that documentation of rural women’sexperience of unsafe and illegal abortionought to be highlighted for local advocacy atdistrict and state level.

Through the network of women’s groupsand the health centre, 25 village womenwere identified who had experienced abor-tion in the last 2 years. All the women weremembers of the ‘mahila mandals’ (self helpgroups), and the author knew them. The 25women are ‘representative’ of the membersof these groups, (most members of the groupsare mainly lower caste, tribal or Muslim; poormarginal farmers or involved in petty trading)although no ‘sampling’ was undertaken.

III. SELECTION METHODThis method of selection was under-

taken for several ethical and practicalreasons:

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1. Almost all abortions in the private sec-tor are ‘illegal’, and most women arevaguely aware of this. It was anticipatedthat women unfamiliar to the groupwould be reluctant to discuss their ex-perience of abortion. Even amongst groupmembers, who were personally knownto the author, some were unwilling todiscuss their experience, and interviewscould not be undertaken. It was onlythrough the women’s groups and thehealth centre that women could be con-tacted, and sufficient trust establishedfor meaningful interviews to be under-taken.

2. It was felt that women would feel reluc-tant to discuss their experience of abor-tion with strangers - since abortion wasan unpleasant experience in their life,best forgotten about. Since the women’shealth centre could not provide freehealth care for post-abortion complica-tions, the question might arise as to theusefulness of divulging such personalinformation. If the woman was experi-encing no current health problem, shewould probably be unwilling to spendtime on the interview.

3. The women selected for this study weremarried and middle-aged and were ac-cessing abortions after completion oftheir families. The author has helpedseveral young, unmarried girls and olderwidows to access safe abortion care overthe last few years. However, these girlsand women were unwilling to partici-pate in this study. Few rural womenseek abortion services as a birth spac-ing method, and usually continue withunwanted pregnancies rather than optfor termination, if their family size hasnot been reached. (This may not be thecase in the urban centres, as reportedby private practitioners, but their expe-rience was beyond the scope of thisstudy)

4. All these interviews were undertakenduring the month of December 2002.Each woman contacted for this study wasapproached firstly by women healthworkers, and then interviewed by theauthor. Most of the interviews took placein the health centre, except those ofwomen who lived more than 15kilometres away. Their interviews tookplace at home. Since each interviewtook more than three hours to complete,restrictions of time also influenced theselection of women.

5. The focus of this study was to collectqualitative data, documenting women’sexperiences. Therefore the ‘sample’ sizeneeded to be kept small.

A semi-structured interview schedulewas utilised to collect information regardingtheir experience of abortion. A copy of thisschedule is provided in Appendix 1. Excerptsfrom these interviews have been includedin this paper to better portray rural women’sexperiences in dealing with unwanted preg-nancies.

Apart from the case studies, interviewswith a small number of service providerswere also undertaken. Questionnaires werenot used, but they were asked about theirmethods, costs, and the problems that theyface.

Only three qualified gynaecologistsagreed to discuss their methods of termi-nating an unwanted pregnancy. All wereprivate practitioners, and were known tothe author earlier. Two were based in Bokaroand one in Dhanbad. Several doctors wereapproached, but few agreed. There are noregistered private MTP centres in the wholedistrict. No private practitioner records thepatients’ pregnancy status and duration,whether an earlier abortion has been per-formed, or the medicines used. Only BGHlegally provides abortion care, but the doc-tors there were not interviewed for this study.

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Five RMPs were interviewed during thecourse of the study. All of them were hus-bands of the group’s members. They were allvillage-based, educated (up to matriculationlevel), lower caste Hindus, and were part-time medical practitioners. The full-time,richer, higher caste RMPs, not known to theauthor, were not willing to divulge any in-formation regarding their methods.

The two female herbal practitioners werealso group members. One was a lower casteHindu, and the other a tribal. Both werepoor, marginal farmers.

Contrary to expectations, these unquali-fied ‘doctors’ (RMPs) and female herbal prac-titioners were much more forthcoming thanthe qualified medical practitioners were, butthat was perhaps because the author knewthem. They were, possibly, ignorant of theillegality of the service they provide. Full-time RMPs, nurses and private medicalpractitioners (MBBS, but not gynaecologists)were not willing to participate in thisstudy.

IV. PROFILE OF THE WOMEN

A profile of the women selected for thisstudy has been provided in Table 1. As canbe seen, all the women are from families ofscheduled castes and tribes, Muslims orother backward castes. The experiences ofhigher caste women in abortion care couldnot be highlighted in this study since thewomen’s groups, and the health centre whichhelped identify the women that had under-gone abortion, work closely and are involvedwith these communities. However the lowercaste, tribals and Muslims do dominate therural parts of the Chas and Chandankiariblocks, where this study was located.

22 out of the 25 women who were inter-viewed for this study had undergone abor-tion in the past 2 years and lived in villagesmore than 16 kilometres away from anyurban centre. The nearest town for most ofthese women was Chas, which lies adjacent

to Bokaro Steel City. Two women from onevillage lived closer to Jharia, which is inDhanbad district.

Only one of their husbands was employedin government service, one was employedin the coal mines, and one more had a smallbusiness. The rest of the women were frompoor families of marginal farmers and dailywage earners. The educational level of thewomen was low, 20 were non-literate, onewas a ‘matric-fail’, one was educated up to7th standard, and three more were only ableto sign their names. The men folk weremarginally better, eighteen were non-liter-ate, two were graduates, two were matricu-lates, one was ‘matric-fail’ and two wereeducated up to Class 7.

The number of children that the womenwho sought abortion had birthed ranged from2 to 7, with the average being 4.1. All ofthem had at least one male child beforeundergoing an induced abortion. Only oneof the women accessed abortion as a meansto space births; the rest had already reachedtheir optimum family size when they de-cided to terminate their unwanted pregnancy.Most villagers here are still unaware aboutsex deter-mination tests, and none of thesewomen aborted a foetus after determiningits Sex.

Neonatal and infant mortality is highamongst these women. 16 women had lostone or more children. 11 women had expe-rienced one or more neonatal death(1 woman had lost 2 babies, and one had lost3). 5 women had lost one or more children(1 woman lost 2 children). Ten womenhad experienced more than one spon-taneous abortion (1 had 2 spontaneousabortions).

Most of the women, since they wereaccessing abortion after completing theirfamilies, were in their early and mid ‘thir-ties. The oldest was 38, and the youngestwas 23. The average age was 31.2 years.

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Table 1. Profile of 25 WomenA. Age Group Number of

Women30 years and below 1231 to 35 years 9Above 36 years 4

B. Social GroupScheduled tribe 8Backward/scheduled castes 9Muslim 6Other Hindu castes 2

C. Educational levelLiterate 2Non/barely literate 23

D. Number of Children2 13 84 85 46 37 1

E. Number of SpontaneousAbortions

0 151 92 1

F. Number of Neonatal deaths0 141 92 13 1

G. Number of Infant Deaths0 201 42 1

V. PREVENTING UNWANTED PREGNAN-CIES : WOMEN’S EXPERIENCE OFCONTRACEPTION

Women resort to abortion with an un-wanted pregnancy. It was therefore useful tounderstand what women in this area hadtried to do to prevent such pregnancies.

A. CONTRACEPTION USE PRIOR TOABORTION

Use of modern, temporary methods ofcontraception for spacing births was low (seeTable 2). 14 of the women had never ac-cessed any sort of method before undergoingabortion. Five women had earlier used oralcontraceptive pills (OCPs), and one had hadan intrauterine device (IUD) inserted (andremoved after 1 year), 2 had used condomsand 3 women had tried herbal medicines.Two of the women who had taken OCPs hadstopped taking them due to nausea anddizziness, another two stopped for fear oflong-term side effects and one stopped be-cause she thought she was too old to con-ceive again. The woman who removed theIUD complained of lower abdominal pain,which she attributed to the device.

Most women, however, are aware of atleast one method of contraception. All of themknew about tubal ligation operations (femalesterilisation), 10 knew that men could alsoundergo vasectomy, 18 knew about OCPsand 17 knew about condoms. Only 7 hadheard of IUDs. Knowledge of accessibility ofall these different methods however was low.Although all knew that sterilisation opera-tions were available in Bokaro GeneralHospital, they remained ignorant about howto actually go and get admission on theirown. The women were not in favour of va-sectomy, and usually laughed at the idea!Most women prefer to access contraceptionor sterilisation themselves, rather thanleave it to the men.

15 of the 18 women, who had heard ofOCPs, knew where to access them, but didnot wish to take pills every day, or wereanxious about their side effects. 14 womenexpressed the idea that women needed to behealthy in order to take OCPs. ‘How could Itake pills every day, do I have enough bloodin my body?’ was stated frequently. The ideathat OCP causes anaemia and weakness iscommon.

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‘I was taking pills for five or six months,but people told me that my blood would dry upif I carried on taking them. So I stopped takingthem. Then I became pregnant again…’ (N Deviof S village)

Two women stopped taking OCPs be-cause they thought their blood would dry up,even though they were not experiencing anyunpleasant side effects.

Most women felt that men would not usecondoms regularly. One woman told us thather husband refused to use them claimingthat his blood would dry up.

Of the 7 women who had heard of IUDs,5 had heard that there are serious sideeffects.

‘I knew about “copper-T”, but villagers toldme that it would lead to cancer. So then I gotit removed. One year later I had to go to get it“washed” again…’ (S Devi of C village)

Four women in this study assumed thatIUDs lead to cancer.

Although there was considerable aware-ness of contraceptive methods, there was agreat deal of misunderstanding regardingthe side effects, particularly over long termuse. Much of the misinformation stems fromthe RMPs, who are found in every village.Since most women are weak and anaemic,and birth spacing methods yield low profits,RMPs often counsel women to consume ton-ics and vitamin capsules to ‘compensate’ forthe adverse effects of OCPs or IUDs. Poorwomen, who cannot afford tonics and vita-min injections, conclude that it is better toavoid contraception.

On the whole women had little accessto accurate information regarding the risksand possible side effects of modern methodsof birth spacing. Few ‘doctors’ - qualified orunqualified - provide rural women withsufficient or accurate information to enablethem to make an informed choice. Thegovernment health workers, on the otherhand, underplay any possible side effect, in

order to fulfil their targets. Consequentlymany women have heard of contraceptivemethods, but are apprehensive about theside effects. They no longer want more than3 or 4 children (unless they have only daugh-ters) which leaves them vulnerable to un-wanted pregnancies. RMPs warn women ofthe risks of contraception, but not of re-peated abortions. Few of the women in thisstudy were aware of the risks of abortion atthe time they had undergone it.Table 2. Contraception Prior to Abortion

Contraceptive Number ofmethod used women

Oral contraceptive pills 5IUD (Copper-T) 1Condoms 2Herbal 3Nothing 14

B. CONTRACEPTION USE FOLLOWINGABORTION

Since undergoing termination of preg-nancy, 18 women have already opted for tuballigation (four had undergone both sterilisationand MTP at the same time in Bokaro Gen-eral Hospital) Two women are now takingOCPs, and one is using condoms. Only fourout of twenty-five women are currently usingno method at all to prevent further concep-tion. (See Table 3)

All the women in the sample who hadundergone ligation, and those who hadundergone MTP at the same time, at BGH,were helped to get admission by the women’shealth centre.

The high number of women who optedfor tubal ligation following abortion is prob-ably due to the help provided by the women’shealth centre of the ‘Mahila Mandal Samiti’in taking women to BGH. It also indicatesthat the women in this sample were not, onthe whole, using abortion as a method ofspacing births. Regardless of caste or com-

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munity women’s preference for terminalmethods of limiting family size is alsobrought out. The health centre provides allmodern methods of temporary birth spacingthat are available in the governmenthealth centres - IUDs, OCPs and condoms -but most women still preferred permanentsterilisation. Women are also counselledagainst repeated abortions, and advised toaccess some method of contraception.

Most women felt that tubal ligation op-erations were more risky than abortion, andneeded more rest and better nutrition thanthey could usually avail. This was the mainreason why four of the women in the samplehad opted for abortion but were not usingany sort of contraception following abortion.

A severely anaemic woman made thefollowing comments, after undergoing threeabortions in fours years, she was of theopinion that tubal ligation operations led toanaemia, but she had no such reservationsabout abortions. Two abortions were per-formed on women who stated that they are‘alone’ when no other working female handsare in the household and therefore preferredit to an operation.

‘When will I manage to go for “operation”?I am alone in this household. If I go for opera-tion I’ll need to rest for at least a month. Whowill do all the housework? And look at me!Am I strong enough? I don’t have enough bloodin my body. You have to be healthy to go foroperation.’ (D Devi, of S1 village)Table 3. Contraceptive Use Following

AbortionContraception Number of

Used WomenOral contraceptive pills 2IUDs (Copper-T) 0Condoms 1Herbal 0Sterilisation (Tubal ligation) 18Nothing 4

VI. THE ABORTION OPTIONS AVAIL-ABLE: SERVICE PROVIDERS ANDTECHNIQUES

In order to terminate an unwanted preg-nancy, village women can ‘choose’ from oneof the following service providers:1. Qualified gynaecologists (Either in

Bokaro General Hospital or private prac-titioners)(MBBS/[Diploma in Gynaecology andObstetrics] DGO) and qualified medicalpractitioners (MBBS) (notgynaecologists),

2. Unqualified medical practitioners (maleRMPs - ‘Rural’ rather than ‘Registered’Medical Practitioner, since few are actu-ally ‘registered’) and unqualified ‘nurses’,

3. Female herbal practitioners (FHPs)A. QUALIFIED MEDICAL PRACTITIONERS

(PRIVATE/GOVERNMENT)Qualified gynaecologists are available for

providing abortion services in Bokaro SteelCity, (either in the Bokaro General Hospitalor in private nursing homes), Jharia(Dhanbad district) and Purulia (in the stateof West Bengal). Village women do not ac-cess abortion facilities at BGH unless theyare willing to undergo tubal ligation, andeven then only if it is not the busy wintermonths. However, they do use these ser-vices if they have experienced a seriousabortion-related complication, which noother private nursing home is prepared tohandle. Most village women do not usuallyaccess abortion services provided by quali-fied gynaecologists, unless complicationshave already arisen as a result of interven-tions by other practitioners. Qualifiedgynaecologists are more expensive than othermedical practitioners, and usually cater tothe needs of richer villagers and the urbanmiddle class. In this study only 3 womenaccessed abortion from a private qualifiedgynaecologist directly, in two cases only afterreferral by the women’s community centre.

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‘I prefer to only terminate pregnancies upto 12 weeks pregnancy, as it is relatively easyand safe. Still there are risks, many of thewomen who come to me are lactating mothersand their uterus is very soft. This makes itmore difficult and risky. I use ‘Prostodin’ tomake the uterus hard in such cases, but thisincreases the cost. I know other doctors aremuch cheaper, but I refuse to take such risks.Many women from villages come with unwantedpregnancies after taking ayurvedic drugs thatare freely available in the shops. They areoften brought by the same RMP that has giventhe medicine to them. In the beginning theyused to tell me, “I’ll take two hundred and youtake a hundred”. Depending upon the relation-ship with the doctor, they dictate in this way.I refuse to oblige them, even if this means theygo elsewhere….’ (Private gynaecologist, Bokaro)

More village women access the ser-vices of private medical practitioners,MBBS-qualified doctors, since they arecheaper than gynaecologists. Most ofthem are based in Chas, which is adja-cent to Bokaro Steel City. They havedeveloped strong linkages with village-based RMPs. Many RMPs have learnttheir ‘skills’ in the nursing homes ofthese doctors.

The qualified gynaecologists and medi-cal practitioners normally conduct abortionsby D&E (dilation and evacuation) method.There is no record on the prescriptions ofany of the qualified private medical practi-tioners that medical termination of preg-nancy has been undertaken. The sort ofprocedure that a woman has undergonewhilst going through an abortion can only beguessed at from her narrative. The medi-cines that have been given, the number ofweeks of pregnancy, are never found inwritten form.

B. UNQUALIFIED MEDICAL PRACTITIONERS

Having learnt their ‘skills’ in the nurs-ing homes of the private medical practitio-

ners, the RMPs receive commissions fromthe doctor when they bring them abortioncases. The unqualified ‘nurses’ that work inthese nursing homes have also learnt their‘skills’ on the job, and sometimes assist RMPsin conducting abortions in the villages ofChas and Chandankiari. These ‘nurses’ aresometimes called by RMPs to conduct abor-tions in village homes where, once again,the latter get around 50 per cent of theservice charges as their commission. RMPsalone are also conducting abortions, usingthe D&E method, in their own ‘nursinghomes’, and sometimes in the home of thewoman.

Most RMPs, however, do not themselvesperform abortions. They administer a vari-ety of medicines, combinations of ayurvedicand allopathic drugs to induce abortion. Theayurvedic preparations they use are admin-istered in the same way as allopathic drugs.These ayurvedic drugs are in tablet/cap-sule form, freely available in chemist shops,and some MBBS doctors even prescribethem.

‘See, if a woman has only missed twomonths, then only these medicines will work.I use “Gynomic Forte” (an ayurvedic capsule).On the packet it’s written once a day, but allof us doctors, including MBBS doctors, give thismedicine twice or even thrice a day. Along withthis I give “Lariago” (chloroquin) for three days.I give antibiotic coverage, like “Tetracycline” forthree days, and vitamin injections of course. Isuppose around 50 per cent are successfulusing these drugs. If this doesn’t work, thenI advise them to go for a D & C. I don’t takethem anywhere, it’s up to them. It’s not worthmy while to spend the whole day to take them,and how much will they pay? Fifty or a hun-dred rupees, it’s not worth it. If they want tocontinue with the pregnancy, then I give BComplex capsules, this compensates forthe earlier drugs and all the babies I’veseen have come out well.’ (A. M, RMP,Chandankiari)

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‘Getting abortions done is no prob-lem at all. If it’s early enough, sayless than two months, then I giveEPForte. This is the main medicinefor causing abortion. It has to be takenwith hot tea, otherwise it won’t work.Of course I give an injection or two,otherwise how can I earn? RPFortedoesn’t cost much. Other doctors give“Lariago”, which is a malaria medi-cine really, but I don’t. I give “chloram-phenicol” by injection. If this doesn’twork, or if the woman is more thantwo months pregnant, then I take herfor a dilation and curettage (D&C) toone medicine shop at the roadside.One doctor from Jharia comes everyweek for doing D&Cs. I round up 3 or4 cases every week for him. The doc-tor gets three hundred and I get twohundred rupees. With medicines thetotal cost is about seven hundred.’ (SR, RMP, Chandankiari)

RMPs are also called upon to give injec-tions if heavy bleeding occurs as a result ofmethods used by other practitioners. They‘partner’ with both MBBS doctors in Chas aswell as female herbal practitioners in thevillage.

C. FEMALE HERBAL PRACTITIONERS

The female herbal practitioners are not,as is commonly assumed, traditional birthattendants or ‘dais’. None of the ‘dais’ in thisarea was found to be conducting abortions.There are, however, several women whohave learnt how to induce abortion. Thesewomen do not normally provide any otherhealth service to women apart from induc-ing abortions.

The female herbal practitioners have avariety of methods. Some administer herbalconcoctions orally, and some insert theminto the cervix of the woman with a stick.Some remove the stick immediately, andsome leave it until it is expelled along with

the foetus. Although these women discussedthe methods they use, they were not pre-pared to divulge the drug composition. Thepopular belief here is that if the compositionis known the medicine becomes ineffective.

‘I learnt from my mother-in-law how tocause abortions. I have to buy some of themedicines, and grind it up with some herbsfrom the jungle. I only give medicines orally.With every month of pregnancy, I simply in-crease the amount of medicine given. I chargeone hundred rupees per month…’ (B Devi, herbalpractitioner, Chandankiari)

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‘I learnt how to do abortions aroundten years ago, when I was working inJharia. One nurse there taught me. Iuse a small neem stick, and I put medi-cines on the tip, which are insertedinto the mouth of the uterus. I bringthis medicine from Katras, it’s notavailable near here. There are moreproblems when the woman is only twoor three months only, the baby isn’tfully formed, and bits get stuck in-side. The best month is the fourth.After the fifth month then sometimesheavy bleeding take place, so I call adoctor to be on hand, so that he cangive injections. I don’t go beyond thesixth month. I give the medicine inthe home of the woman, or I send herhome after giving it to her here. Idon’t want her aborting here in myhouse. Sometimes the baby is bornalive, now what would I do then? Itell them all that if anything goeswrong, it’s their problem. They’ll haveto make arrangements to go to somehospital. Most of the women who cometo me are tribals, especially unmar-ried girls. I charge one hundred ru-pees for every month of pregnancy….’(FD, herbal practitioner, Chandan-kiari)

VII. DEALING WITH UNWANTEDPREGNANCIES: RURAL WOMEN’SEXPERIENCES OF ABORTION

A. DECISION-MAKING AND ABORTION

The decision to undergo an abortion wasin all cases made by the woman, or thewoman along with her husband. In no casewas the woman forced to undergo abortionagainst her wishes. In 3 cases the womeninduced abortion without the prior knowl-edge of their husbands.

‘First of all I went to the doctor who sitsin our village. I didn’t tell my husband at thattime. He would have said, “Let the child beborn, I’ll take care of it.” But I’d had enough.I have six children - and two who are no more.So that doctor called one nurse fromChandankiari. He gave me an injection andshe gave me some pills. I had only missed twomonths then. I started bleeding soon after, butthe main thing was stuck inside. I carried onbleeding for a month. Then he called anotherdoctor. He said the placenta was stuck inside.Then I went to Chas to a nursing home. Thedoctor said I was more than three months atthe time.’ (R Bibi, village, Chandankiari)

‘I went alone to the woman for abortion.I only told my husband later. What was theneed of him knowing? He’s not that bothered.’(S Devi, S2 village, Chandankiari)

The men folk, however, often influencedthe sort of service accessed. Knowledge ofthe different methods of aborting unwantedpregnancies is widespread. Thirteen womenwho consulted the doctor at the ‘MahilaMandal Samiti’s health centre prior to theabortion were informed about the optionsavailable to them, and the risks involved.Five women who did not consult the healthcentre were guided by other village women,four by their husbands and three by localmedical practitioners.

‘I came here when I had only missed onemoon, and you told me to go for abortion inBokaro, and to discuss what to do with my

husband. Well he talked to a “doctor” in Babudiwho said he’d get it done. So he brought one“doctor”, who brought along a “nurse” fromChas. She came and inserted some pipe intome. God knows what she did. I started havingsevere cramps, and bleeding, but nothing cameout. The “doctor” brought the “nurse” backagain in the afternoon, and she put these bigspoons inside me. I don’t know what came out,but I carried on bleeding for a month. After thatI had to go for another “wash” in Bokaro….’(J Bibi, A village)

‘I had gone along to the “doctor’s” housewith another woman from our village. The vil-lage “doctor” had told my husband that hecould get a “wash” done for three hundredrupees only. He wasn’t a real “doctor”, or itwouldn’t have been so cheap, would it? Whenthe other woman started screaming inside I ranaway. I thought, “I’m not going to have thatdoctor sticking instruments into me.” But myhusband came after me. He had to almost dragme back. …After one month I started bleedingheavily, it just didn’t stop. I had to get another“wash” done. But the second time I went to aproper doctor, and my father paid.’ (S Bibi, Bvillage, Chas)

‘I didn’t want to go to that place (nursinghome of RMP in Chandankiari). When I sawhim with these big scissors, don’t you think Iwas scared! I thought I was going to die. Butwhat to do? Where could I have gone? He (herhusband) took me there because it was cheaperthan the doctors in Bokaro. Only us poor peoplehave to take such risks.’ (S2 Devi, village,Chandankiari)

Women admitted that they did notwish to be burdened with unwantedpregnancies, and they often take thedecision to abort, but they are not ableto access quality abortion services in-dependently. Safe abortion servicescost money and necessitates travellingto nearby towns, and this is where meninfluence the sort of provider accessed.Safe abortion is less of a priority formen than their wives.

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B. THE ABORTION EXPERIENCE

Only 5 women accessed early first tri-mester abortion, within less than 10 weeksof pregnancy. 17 were between 11 and 14weeks pregnant at the time of abortion, and3 were more than 15 weeks pregnant. Ac-cessing abortion from a qualified medicalpractitioner usually took place in the sec-ond trimester, after women had tried other,more accessible methods. This obviouslyadds to both risk and expense.

The women revealed that all methods ofabortion, by all types of providers, result incomplications. Infections were common fol-lowing abortions. Few women were givenany advice regarding means to prevent in-fection. Women who accessed abortionservices from a RMP or FHP were rarelygiven any antibiotics. RMPs usually gaveinadequate doses and incomplete courses ofantibiotics. All women, however, were giveninjections of vitamins and sometimes‘Methergin’ to prevent bleeding together witha bottle of tonic. Five women complained ofserious infection following the abortion.

‘The doctor told me nothing about keepingclean or about not staying with my husband.I took a bath in the pond the next day…’ (ADevi, village J )

Heavy bleeding following abortion wascommon. Eight women said they experiencedsuch heavy bleeding that they needed fur-ther treatment. In 6 of these cases RMPswere involved in conducting the abortion.This, however, is probably under reportedsince many women expect heavy bleedingand even worry if they bleed very little. Onewoman had an MTP by a qualifiedgynaecologist, after having experiencedone earlier in the village, induced by anRMP.

‘The first time I had an abortion I bled fora whole month. For the first week I lost a hugeamount of blood. This time I hardly bled at all,only a small amount for one day. I thought the

doctor must have left the thing inside!’ (C Devi,C village)

5 women had to undergo D&Cs twicedue to retained foetal parts, which hadcaused continuous bleeding.

Many women had to use the servicesof a variety of providers and techniquesto terminate an unwanted pregnancy.15 out of the 25 women in the surveyused the services of more than one pro-vider. Only three women had a ‘safe’abortion from a single, qualified, ser-vice provider. What was striking was theuse of a combination of service provid-ers when complications occurred, due tothe ineptitude of the practitioner. Onlyin one case was the complication, whicharose from the MTP, managed by thesame practitioner, a qualifiedgynaecologist.

Table 4 gives an idea of the number ofservice providers women are accessing inorder to terminate an unwanted pregnancy.The role of the RMPs in providing abortionservices was found in 14 cases. In 2 casesthe RMP performed the abortion himself,without assistance from another practitio-ner. Although RMPs conduct medical abor-tions, in most cases they act in combinationwith other practitioners, often as touts oragents.

In 4 cases MBBS (including one DGO)doctors performed D&Cs after the RMP hadfailed with ayurvedic/allopathic combina-tions. In 3 cases the ‘nurses’ and RMPsperformed the abortion together, with 2 ofthese cases resulting in serious complica-tions (heavy bleeding due to incompleteabortion) needing further treatment and D&Cfrom a qualified doctor. In 5 cases RMPswere called to stop bleeding after the min-istrations of the female herbal practitioner.In one of these cases the woman had toundergo another D&C from a qualified medi-cal practitioner.

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Table 4. Abortion Service ProvidersAccessed by Women

Service providers Number ofwomen

MBBS/DGO only 3MBBS only 2RMPs only 2FHPs only 3RMPs + MBBS 3‘Nurse’ + RMPs (together) 1RMP + MBBS/DGO 1RMP + ‘nurse’ (together) + MBBS 2FHP + RMP 3FHP + RMP + MBBS 2MBBS/DGO(2 different providers) 2MBBS + MBBS/DGO 1

Although Bokaro General Hospital isthe only ‘safe’ and ‘legal’ abortion serviceprovider in the district, it is also the leastwoman-friendly. None of the women in thestudy could have accessed abortion careindependently, even though they acceptedsterilisation as a pre-condition.

Women who accessed ‘safe’ abortionservices from BGH also encountered compli-cations. Four women in this study had abor-tions along with tubal ligation operations,yet two of them had to use the services ofanother, private, gynaecologist, followingcomplications.

‘The day after coming home from thehospital I had severe cramps in my belly,then I squatted and pieces of flesh andbones came out. Then the pain reduced abit, but I kept on bleeding for a month. Itook medicines, but you know what hap-pened. I had to have another abortion…’(M Devi of village C)

The woman above aborted another foe-tus at home, after MTP had supposedly beencompleted. It was probably a twin pregnancy.

After one month of bleeding due to retentionof foetal parts a private gynaecologist didanother D&C. Yet other woman accessedthe services of another private gynaecologistfollowing severe infection after having anabortion at BGH. Treatment of any compli-cations resulting from MTP and tubal liga-tion operations at BGH are not provided freeof cost, so women normally do not returnthere.

One woman in the sample who had goneto BGH for MTP and tubal ligation continuedto remain pregnant.

‘After two months I still didn’t see anymenstruation. I felt sick and realised I was stillpregnant. But after leaving the hospital I neverwanted to return! When they were doing theoperations I could see everything. I was lyingthere and this doctor with big scissors andblood all over her hands was standing over thenext woman…I wanted to run away, but it wastoo late. Never, never will I return to that place.My husband called the “doctor” from the nextvillage. He came and gave some injections andmedicines, but nothing happened. Then hecalled another “doctor”. He gave some moreinjections…but still nothing came out. Then myhusband, he knows a bit about herbal medi-cines, you know, he brought me some medicinefrom the jungle. After that I started to bleed. Icarried on bleeding for a month, but the mainthing was stuck inside. We called the firstdoctor back again; he gave me some moreinjections. But they didn’t do any good. I wasso weak by then I could hardly walk. My aunthere was giving me an oil massage; we werewondering what to do. She knows a thing ortwo about these things; she helps us all duringchildbirth… Anyway she called for some coco-nut oil, and the help of a couple of other women.They held me down whilst she inserted herhands into me and pulled the thing out. I thoughtI was going to die….’ (H Devi, B village)

H Devi was clearly more terrified ofthe doctors, with their scalpels and for-ceps, than her aunt’s bare hands.

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(Whilst the above interview was takingplace in B village another woman came toshow me her small baby. She had also beenpregnant at the time of tubal ligation, butdecided to continue with the pregnancy.Childbirth following ligation operations arenot uncommon)

C. COST AND ABORTION CARE

Cost is one of the main obstacles thewomen faced in looking out for safe abortioncare. The women who access FHPs and RMPsare initially fully aware of the risks involved,expecting costs of the abortion to be lessthan that charged by qualified doctors intowns, and they can only hope complicationsdo not arise.

The cost of terminating unwantedpregnancies for village women is heavy,financially as well as physically. Thecheapest was Rs.200 for terminating a2-month pregnancy by a FHP. The mostcostly was Rs.2, 200 which was the totalcost of an incomplete abortion by aRMP and ‘nurse’ in the village, followedby another D&C by a qualified doctor.The average cost of abortion in thisstudy was Rs. 1, 066.

Private medical practitioners’charges often exceeds the total cost ofqualified gynaecologists, but they al-low the woman’s family to pay byinstalments. RMPs vary their chargesaccording to the capacity of the womanto pay, or play on their ignorance. Onewoman, a non-literate, tribal woman wasgullible enough to pay Rs.800 to anRMP for a D&C, whereas his normalcharge is around Rs. 500.

‘I knew the risks involved. But we are poorpeople. She (the herbal practitioner) only takesone or two hundred, and we can pay byinstalments. If we go to a big doctor in town,just going and coming will cost more than that.And we have to pay the doctor beforehand. Butwith her, we pay her off whenever we can.’ (S3

Devi of S2 village of her induced abortion bya FHP)

Not only does the cost considerationdetermine ‘choice’ of provider, but it oftendelays accessing an abortion.

‘I was around four months pregnant whenI finally got it out of me. I knew I was pregnantafter the first moon, but what to do? I went tothe doctor, and she told me it’d cost four hun-dred. So we came home and saved up fourhundred. This took two weeks. Then she toldus it would be six hundred. We saved up somemore. In the end we paid almost a thousand.’(M Devi, S1 village, Chandankiari)Table 5. Cost of Abortion

Cost of Abortion Number ofand complications Women

Less than Rs.500 9Rs. 501 to Rs.1000 10Rs.1001 to Rs.2000 4Above Rs.2001 2

D. ACCESSIBILITY AND ABORTION

Accessibility is another reason whywomen did not utilise safer abortion ser-vices. Women can access RMPs and FHPseasily and independently, which is not thecase when it comes to a qualified practitioner.

Many of the women were more at easeusing the services of known practitioners,either the village ‘doctor’ or the female herbalpractitioner. Women often turn to theseproviders first because this is within theircapacity. They can go to them without thepresence of men, it does not need largeamounts of money, and the practitionersare nearby. To access abortion services ofa qualified doctor necessitates the supportof their husband, both financially and physi-cally, since most medical practitioners inChas and Bokaro insist on the husband’spresence. And to use the services of BGH,accepting sterilisation along with abortion,necessitates the support of the husband (to

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sign the admission papers) and staff fromthe women’s health centre. It may alsonecessitate several visits spread over manydays, before the operation is performed.E. IMPACT ON WOMEN’S HEALTHl The impact of repeated D&Cs and in-

duced abortions on women’s health canbe well imagined. All the women in thesurvey were found to be anaemic. Ninewomen were mildly anaemic, elevenwere found to be moderately anaemic,and five were found to be suffering fromsevere anaemia.

l 16 women were found to be sufferingfrom vitamin deficiencies, whilst almostall (23) complained of weakness follow-ing the abortion.

l Currently, six women were found to besuffering from severe pain in the lowerabdomen, due to reproductive tract in-fections.

VIII. CASES OF ABORTION-RELATEDDEATHS NOT INCLUDED IN THISSTUDY

During the course of this study 4 abor-tion-related deaths were discovered in nearbyvillages. The villagers who narrated the de-tails of these deaths were all of the opinionthat abortions were the cause of death.1. S DEVI, J VILLAGE

According to the women of the village,Saraswati’s death was the result of repeatedabortions. She had undergone three abor-tions over the last four years. Two abortionswere undertaken by an RMP who has a‘nursing home’ in Chandankiari and an-other by a qualified medical practitioner inChas. During her last unwanted pregnancyshe had approached the women’s healthcentre, and she was advised to access abor-tion care in a qualified doctor’s nursing homein Bokaro. Instead she was taken by herhusband, and another man from her village- who has become an agent for that RMP -for a cheaper abortion, in the ‘nursing home’

that he set up. Another D&C was performed.She already had four children. Her husbandremarried one year later.

‘She refused to go for sterilisation, shewas scared. The “doctors” never told her aboutthe risks of having abortions. Why shouldthey? They are only interested in money, aren’tthey? Every year she got weaker, but still shewent for abortions. Ultimately, her uterus gotinfected and nothing could be done….’ (J Devi,S’s neighbour, J Village)2. F DEVI (S VILLAGE)

In F’s case, her husband called an RMPfrom another village. He, in turn, brought a‘nurse’ to help perform an abortion in thehome of the woman. She had four childrenand her husband has since remarried.

‘The husband called me in the night, I sawa huge pool of blood, and the woman wasbarely conscious. I told them there was noth-ing I could do; it looked like her uterus hadbeen ruptured to me. I told them to get her toa hospital immediately, but next day he tookher to her father’s house instead. She neverreached a hospital, but died there in her father’shouse…’ (S M, RMP, Simulia)3. J BIBI (K VILLAGE)

J’s abortion-related death was causedby the combined services of a RMP and FHP.In this case the woman concerned had cometo the women’s health centre for help interminating an unwanted pregnancy. It wasduring the busy winter months at BGH, whenMTP along with ligations are not admitted.She was advised to get an abortion privately,at the nursing home of a qualifiedgynaecologist. Since she already had sixchildren and was then in her second tri-mester, it was risky. She was asked todiscuss it with her husband first. Insteadher husband called an RMP and FHP. Herhusband remarried one year later.

‘After you’d told her that her abortion mightcost around Rs.800, her husband called the“doctor” from the shop on the roadside. The“doctor” told him not to waste so much money,

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he’d give some medicines instead. He gavesome medicines and injections, who knowswhat he did, but the main thing didn’t comeout. She bled and bled. Then he called the oldwoman, (a FHP). She inserted a stick insideher and left. Then she really bled. Next morn-ing we took her to Chas, but the nursing homewouldn’t admit her. The doctor there took onelook inside her, saw the stick, and told us toget to BGH fast. Somehow we got the Rs.5000needed to get her admitted. Then they operatedon her, removed her uterus, and gave her blood.But still she died by evening. The doctor toldus that the stick had gone right through to herstomach….’ (J1 Bibi, J’s neighbour, K Village,)

4. A DEVI (B VILLAGE)The last, most recent case took place in

a nursing home of a gynaecologist in Bokaro.‘We had gone to that nursing home be-

cause they had advertised all over Chandankiarithat abortion only cost Rs.299. They also saidthey could perform sterilisation as well…Whenshe went into the operation theatre she wasfine. The doctor told me to come back in theafternoon… When I reached I saw the doctoralong with some of her staff bundle my wifeinto an ambulance, with a bottle of salineattached to her. They told me she was havingtrouble, and needed to get to BGH fast. Onreaching BGH the doctors told me she musthave died around two hours earlier…’ (A P,husband of deceased, B Village, Chandankiari)

The first three deaths outlined aboveinvolve RMPs, and the role of husbands incalling them in for abortions. In two of thesecases, S and F, they were subjected to D&Coperations at village level. Unqualifiedmedical practitioners performed the D&Cswithout taking basic precautions. The com-plications were serious, and poverty, igno-rance and callousness led to their death.

In the last case, however, the doctorwas qualified, but death still occurred. Thenursing home’s abortion services have beenwidely advertised throughout Bokaro, in boththe city and villages. The doctor could not

manage the complications, nor did she referthe patient fast enough to BGH. The costof admission to BGH, which was to be bornby the patient, was not immediately avail-able. The husband was rightly angry thatthe doctor referred a dead body to BGH, sothat a death certificate could not be arranged.This death reminds us that abortion alwayscarries a risk, and unless timely referral isavailable, the consequences can be fatal.IX. DISCUSSION

Due to the small sample size, and thewide spectrum of experiences, it has beendifficult to make generalisations. It is clear,however, that good quality, accessible andaffordable abortion services for village womenare not available.

Women are aware of the risks involvedin accessing abortions. They juggle acces-sibility, affordability and quality, since allthree are not available. A qualifiedgynaecologist may be ‘safe’, but is inacces-sible and too expensive for most villagewomen. At the other end of the spectrum,a female herbal practitioner is the mostaccessible and affordable, but less safe. In-between these two, there is a huge numberof combinations of abortion providers. Fif-teen women in our study accessed servicesfrom a combination of providers, indicatingthe inadequacy of the method used. It alsoshows that care providers cannot, on thewhole, deal with complications arising fromthe method they are using.

By having to combine methods and ac-cess services from several providers womenpay heavily in terms of cost and health. Thedelays due to method failure and incompleteabortion, the complications that arose addedto cost and risk. Few women could accessearly first trimester abortion care, with mostwomen (17) terminating their pregnanciesbetween 11 and 14 weeks. Women alreadyweak and anaemic had to put themselves atconsiderable risk to terminate an unwantedpregnancy.

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There were a large number of women inthe sample who had availed of the servicesof herbal practitioners, but the rate of com-plications reported by these women was lessthan those that had accessed abortions fromRMPs. The use of the D&C method by RMPsand unqualified ‘nurses’ resulted in the mostserious complications - ruptured uterus -which cannot be treated in any governmenthospital in the Bokaro district. RMPs werecrucial in providing abortion services, andgained financially from its promotion. Noneof the women in this study, who went toprivate medical practitioners (MBBS or RMPs)for abortions were given advice regardingbirth spacing or means to prevent infection.RMPs often act as agents for private medicalpractitioners, which substantially increasesthe cost to the woman. In some cases this‘commission’ is almost as much as theservice providers’ fees.

The use of ayurvedic medicines thatare easily available is also a matter of con-cern. Many ‘doctors’ (qualified and unquali-fied) tell women to ‘try these drugs first’.This delays accessing abortion services andadds to both the cost and risk. Many women,however, continue with pregnancies afterthese medicines have failed. The impact ofthese drugs on the foetus is not known.

Women who accessed abortionthrough private practitioners wererarely counselled regarding contracep-tion, nor did they warn women of therisks of repeated abortions. The ‘prof-its’ to be made from providing abortionby private practitioners are consider-able, and the incentive is for repeatedabortions rather than contraception.

Women who succeeded in effecting abor-tion along with sterilisation from BokaroGeneral Hospital, were all helped to getadmission, counselled regarding the proce-dure, provided pre- and post-operative carefrom the Mahila Mandal Samiti’s healthcentre. Bureaucratic procedures coupled

with the hospital staff’s behaviour and re-peated visits that it entails, are all factorsthat deter women from approaching BGH.

In spite of abortion services not beingmade available, many women in this studyinitially approached the MMS’s health cen-tre for terminating an unwanted pregnancy.However, the women’s health centre cannotreally refer women for safe, affordable andaccessible abortion care, since this servicedoes not exist. Women with unwanted preg-nancies are often advised to continue withthe pregnancy rather than utilise unsafeabortion services if their optimum familysize has not been reached. Women whosuffer health problems (heart disease ortuberculosis for example) are similarly ad-vised due to the lack of emergency carewithin the district for emergencies. Theabortion-related deaths as well as the highnumber of complications, also points to thedire need for government hospitals to pro-vide emergency care within the district.

Neither government nor private healthsectors place women’s health on theiragendas. Either they are a source of profit,or targeted for population control. It istherefore unrealistic to expect women-friendly abortion services, which providecounselling, accurate information, andquality care from either sector.

The sensitivity of the abortion issue,both from a legal as well as a women’s rightsperspective, leads us to argue in favour ofproviding safe and accessible abortion inwomen-centred health care facilities. Onlywhen women’s overall well being is theprinciple concern of the health care pro-vider, can safe abortion care be made acces-sible and available. Until such a service ismade available, poor women do not have anyreal ‘choice’, nor do they have a decisionmaking role in their own fertility. Thisstudy clearly shows that women’s controlover their own bodies and their fertility isat variance with existing options for abor-tion care.

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Appendix 1 : Abortion Assessment Schedule1. Name:2. Husband’s name:3. Distance from urban centre:4. Age:5. Family Income:6. Educational status:

a) Wifeb) Husband

7. Number of live children:a) Boys:b) Girls:

8. Number of:a) Spontaneous abortions:b) Neonatal deaths:c) Child deaths:d) Induced abortions:

9. Total number of pregnancies:10. How long ago did the abortion take place?11. When was the pregnancy confirmed?

a) 4-6 weeksb) 7-10 weeksc) 11-14 weeksd) 15 plus weeks

12. When was the decision to abort pregnancy taken?a) 4-6 weeksb) 7-10 weeksc) 11-14 weeksd) 15 plus weeks

13. Who decided to abort pregnancy?

APPENDIX

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14. Had any birth spacing method ever been used?a) Which method?b) Was any contraception being used at the time of conception?c) Why did they stop using birth spacing method?

15. If no method of birth spacing was used, did you know about —?a) Ligation (tubectomy)b) Vasectomyc) Oral contraceptive pillsd) Copper-Te) Natural family planning

16. Why was no method of birth spacing accessed?17. Did you know where to access these different methods?18. Who provided information about abortion services?19. Were you aware of the risks involved?20. Did anyone inform you of the risks beforehand?21. Were you aware of the different methods of abortion and their risks?22. What method of abortion was accessed?23. Where was it undertaken?24. What were the qualifications of the practitioner?25. Did any complications arise?26. Who managed the complications, if any?27. Did the practitioner provide any advice regarding:

a) Possible risks/side effects/need for follow-up?b) Possible infection and need for prevention?c) Birth spacing?

28. What was the total cost of the abortion (and complications, if any)?a) Medicinesb) Service chargesc) Other costs

29. Were you suffering from any other illness at the time?30. Are you presently suffering from?

a) Anaemiab) PID/STD/RTIc) Weakness/Vitamin deficiencies

31. Has any birth spacing method been subsequently accessed?32. Would you undergo the experience again if pregnant again?

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ABOUT THE AUTHOR

Lindsay BarnesLindsay Barnes is a social activist, living and working

in a backward part of the Bokaro district for the last fifteenyears. She has lived there since completing her doctoralthesis from Jawarharlal Nehru University on the strugglesof the women colliery workers in the nearby Jhariacoalfield, in 1989.

She has been involved with issues facing villagewomen, and has helped set up a federation of self helpgroups, the ‘Mahila Mandal Samiti’, which is a grass rootswomen’s organization with around 5000 members.Women’s health activities have been prioritized since thebeginning. The federation has its own women’s healthcentre, and Lindsay has encouraged and trained villagewomen to become ‘barefoot gynaecologists’. She has at-tempted to promote ‘self help’ in the sphere of women’shealth and micro credit.

Alongside these activities Lindsay also contributesarticles for various newspapers, writing on developmentand women’s health issues. She lives in the village withher husband and two children.