- An estimated 1.25 million abortions occurred in Bihar in 2015. These included safe and unsafe abortions, and those taking place both in health facilities and in other settings. The state’s abortion rate was 49 terminations per 1,000 women of reproductive age.
- The large majority of abortions (79%, or 992,100) took place in nonfacility settings using medical methods of abortion, and 5% (64,500) were performed outside of health facilities using other methods.
- Only 16% of abortions (194,300) occurred in health facilities. Private facilities provided nearly all facility-based terminations (92%).
- An estimated 2,834 facilities in Bihar provided abortion-related care (induced abortion, postabortion care or both types of services) in 2015; 22% were public and 78% were private. Seventy percent of public facilities reported offering no abortion-related care.
- The vast majority (91%) of health facility abortions took place in the first trimester of pregnancy (up to 12 weeks’ gestation), and slightly more than half (52%) occurred at less than eight weeks’ gestation. Most facility-based abortions were performed surgically using manual or electric vacuum aspiration (43%) or either dilatation and evacuation or dilatation and curettage (31%).
- Although nearly nine in 10 women of reproductive age in Bihar live in rural areas, only 31% of facilities that provide any abortion-related services were located in rural areas. Among facilities that offered such services, fewer than 10% of hospitals—the facilities best equipped to handle severe complications or later-term abortions—were located in rural areas.
- Nearly half (48%) of pregnancies occurring in Bihar in 2015 were unintended. The majority (55%) of these unintended pregnancies ended in an abortion.
Context of Abortion in India and the State of Bihar
Although abortion is legal in India, evidence on how many abortions occur and under what circumstances they are performed is limited. Official incidence statistics come from the Family Welfare Yearbook published by the Ministry of Health and Family Welfare (MoHFW), Government of India; these statistics underestimate abortion incidence because coverage of facility-based services is incomplete and many abortions take place outside of facility settings.1 The most recent (and most commonly cited) study to have estimated abortion incidence in India was based on a small sample of facilities and likely underestimated the true magnitude.2 The data in this study are also now more than 15 years old, and demographic factors that influence abortion and conditions surrounding its provision have changed markedly over this period.3-5 Until now, the country has lacked a large-scale study of abortion service provision in both public and private health facilities that documents the care provided and its quality, captures nonfacility abortions, and gives reliable estimates of the incidence of abortion and unintended pregnancy.
To fill this gap in data, we undertook a rigorous study, titled An Assessment of the Incidence of Unintended Pregnancy and Abortion in India (UPAI), which employs a modified version of the widely used abortion incidence complications methodology.6-8 It covers six states of India—Assam, Bihar, Gujarat, Madhya Pradesh, Uttar Pradesh and Tamil Nadu—that together account for about 45% of the country’s population and were chosen to represent each region of the country. For each state, the study
- provides representative, in-depth information on the characteristics of abortion-related services (induced abortion and postabortion care) provided by each type of public- and private-sector facility in 2015;
- uses facility-based abortion data from the six states and national data on medical methods of abortion (MMA) sales to estimate abortion incidence; and
- uses abortion incidence data to estimate levels of unintended pregnancy, an important indicator of women’s ability to regulate their fertility.
This report focuses on Bihar, first providing detailed findings on facility-based abortion and postabortion services in the state, then using these and other data to formulate estimates of the incidence of abortion and unintended pregnancy. In the final section of the report, we offer recommendations to facilitate planning for improvements in the accessibility and provision of safe, high-quality abortion services.
Abortion Law in India
Induced abortion has been legal in India on a broad range of grounds since the Medical Termination of Pregnancy (MTP) Act was passed in 1971. According to this law, abortion is permitted up to 20 weeks’ gestation when it is necessary to save a woman’s life or protect her physical or mental health, and in cases of economic or social necessity, rape, contraceptive failure among married couples and fetal anomaly.9 Pregnancies beyond 20 weeks may be terminated in cases of life endangerment. The MTP Act mandates that abortions take place in safe and hygienic conditions at approved facilities and be performed by certified providers. Providers eligible for certification are limited to obstetrician-gynecologists or doctors with a bachelor of medicine, bachelor of surgery (MBBS) degree who have undergone MTP training.
All public facilities at the primary health centre (PHC) level or higher are approved to provide abortions, as long as they have a certified provider on staff. Facilities lacking the necessary equipment are expected to have referral linkages to higher-level sites. Private facilities, on the other hand, must become registered to provide legal abortion services, a process that entails meeting criteria specified by the MTP Act. Registration is difficult, in part because the District Level Committees responsible for approving private facilities do not exist in some areas and may meet infrequently in others. A study conducted in Bihar found that none of the state’s private facilities providing abortion in 2010 were registered to do so.10 However, lack of registration does not imply that the abortions provided in those facilities are unsafe, as unregistered facilities may have qualified, trained staff performing safe abortions.
The MTP Act of 1971 has been amended to address advances in abortion methods, and these and other policy changes have contributed to expanding access to MMA, which, in India, refers primarily to the use of a combined regimen of misoprostol and mifepristone (whether packaged separately or together in a “combipack”). The use of MMA to terminate pregnancies up to seven weeks’ gestation was approved in 2002; subsequent amendments to the MTP Act and accompanying rules allowed private providers to become certified to offer abortion and permitted certified abortion providers with referral linkages to approved facilities to offer MMA, even while working at unapproved facilities (thus facilitating prompt action in case of complications).*12-14 The amendments also attempted to improve the process of registering private facilities by speeding it up and shifting responsibility from the state to District Level Committees. In 2008, the combipack, which contains 200 mg of mifepristone and 800 mcg of misoprostol, was approved in India.15 Amendments to the MTP Act have been proposed that would expand the range of providers legally able to offer early first-trimester abortion to include nurses and auxiliary nurse midwives (ANMs), as well as practitioners trained in Indian systems of medicine with recognized qualifications; allow terminations at a woman’s request up to 12 weeks’ gestation; allow abortion in cases of contraceptive failure for all women and couples, regardless of marital status; increase the gestational age limit for abortion to 24 weeks for certain vulnerable groups; and remove the gestational age limit for terminations sought because of diagnosed fetal abnormality.16 At the time of this writing, none of these proposed amendments had been passed.
Policies have also been written to address the use of sex-selective abortions. Cultural norms and discriminatory practices that favor males, including sex-selective abortion, have resulted in an imbalance in the sex ratio in India: As of 2014–2016, there were 848 females per 1,000 males at birth.17 To ameliorate this imbalance, the government enacted the Pre-Natal Diagnostic Techniques Act in 1994,18 amended in 2003 to become the Pre-Conception and Pre-Natal Diagnostics Techniques (PCPNDT) Act, which prohibits the misuse of prenatal diagnostic tests for the purpose of sex determination.19,20 Challenges remain, however, in simultaneously addressing gender-biased sex selection while protecting access to legal abortion services. The Government of India’s strict measures to enforce the PCPNDT Act, as well as intense public focus on this issue in recent years, has generated the misperception among women and providers that all abortions are illegal, and has thus led to difficulties in both obtaining and providing safe abortion and postabortion care.21-23
In addition, facility-based provision of safe abortion services is hampered, at least in the public sector, by shortages of trained personnel, lack of necessary equipment and frequent transfers of trained providers to unequipped facilities.24 The 2012–2013 District Level Household and Facility Survey found that in the country as a whole, 26% of district hospitals and 77% of community health centres (CHCs) did not have a gynecologist on staff.25 In the private sector, as well, providers lack training opportunities to learn how to perform abortions, and trained providers may not work in facilities that are registered to provide the service.10
Sexual and Reproductive Health and Abortion in Bihar
Abortion and unintended pregnancy are closely linked to contraceptive use and other indicators of women’s status, such as age at marriage, literacy and level of urbanization, all of which may be associated with women’s and couples’ desire to control the timing of their births and to limit their fertility.
As one of India’s most socioeconomically disadvantaged states, Bihar is among the eight states included in the Empowered Action Group targeted for special government interventions to address rural health. Of the 25.3 million women of reproductive age (15–49 years old) in the state in 2015,26 87% lived in rural areas,27 and in 2011–2012, 34% of all people residing in the state lived in poverty.28 Unsurprisingly, the state lags behind the rest of the country on various measures of sexual and reproductive health.
According to data from the 2015–2016 National Family Health Survey (NFHS-4), only 23% of all married women of reproductive age in Bihar were using a modern contraceptive method, compared with 48% in India as a whole (Table 1).27,29 Moreover, this proportion has declined in Bihar over the past decade, from 29% in 2005–2006, an unexpected trend.30 The vast majority of married women who practice modern contraception use female sterilization (89%);27 although this method is appropriate for women who want to cease childbearing, it does not address the needs of women seeking to space births.
Despite the decrease in contraceptive use, the proportion of women with an unmet need for contraception—married women who are able to become pregnant and want to prevent pregnancy for at least two years but who are not using contraceptives—declined slightly in the past decade, from 23% to 21%.27,30 Nonetheless, the level of unmet need remains high, especially compared with 13% for India as a whole.29 Unwanted fertility in Bihar was also substantial in 2015–2016: On average, women in the state wanted 2.5 children but had 3.4—about one more child than they wanted, and one more child than the 2.2 children women in India have on average.27,29 There has been some change over time in the gap between the rates of wanted and total fertility: It dropped from 1.6 children in 2005–2006 to the current gap of 0.9. 30
Data on the timing of marriage show that the median age at first marriage for women aged 20–49 increased substantially over time in Bihar, from about 15 years in 2005–2006 to roughly 18 years in 2015–2016.27,30 More than three-quarters (76%) of women aged 15–19 were unmarried at the time of that last survey, compared with 54% in the previous survey. The increase in age at marriage has likely contributed to the decline in the total fertility rate and to trends in related indicators.
An important contributing factor to unintended pregnancy and abortion incidence is the extent to which unmarried young women are sexually active. Data on this behavior in Bihar are extremely limited, and those that exist are likely to reflect a high level of underreporting, given the strong social sanctions against sexual activity outside of marriage. According to the 2007 Youth Survey, in Bihar, about 3% of all women aged 15–24 (2.4% of those who were married and 3% of those who were unmarried) reported having had premarital sex with a male.31 Among males this age, 14% reported having premarital sex with a female. The increase in marital age may be contributing to an elevated likelihood of women’s becoming sexual active and experiencing unintended pregnancy and abortion before marriage.
Rising literacy is generally associated with an increase in women’s role in decision making regarding matters such as contraceptive use, timing of births and family size. The NFHS shows that women in Bihar made important gains in literacy over the past decade: The proportion of those aged 15–49 who were illiterate dropped from 63% in 2005–2006 to 50% in 2015–2016.27,30 Further analyses are needed to understand the relationship between gains in literacy in the state and sexual and reproductive health behaviors.
A few previous studies have provided estimates of abortion in the state, but each has relied on incomplete sources of data. Data from 2014–2015 on the incidence of abortion in Bihar, compiled by the MoHFW, showed 4,877 induced abortions occurred in a 12-month period.1 In 2012, a study using two indirect estimation techniques (the Mishra-Dilip method and the Shah Committee’s method) placed the state’s induced abortion incidence far higher, at 414,000–608,000 per year.32 Another attempt to estimate induced abortion in Bihar used official records from the Health Management Information System and the abortion ratio from the 1998–1999 National Family Health Survey (NFHS-2) multiplied by the crude birthrates projected to 2011 from the 2008 Sample Registration Survey to indirectly estimate incidence.10 This effort yielded 384,999 abortions in Bihar between April 2010 and February 2011.
In addition to these studies, community-based surveys of women (such as the NFHS) collect some data on abortion but are not a reliable source for estimating incidence because, in response to the stigma associated with terminating a pregnancy, women typically underreport their abortions in face-to-face interviews, a problem that may be exacerbated if women believe abortion to be illegal. The estimation methodology used in our UPAI study improves on those of previous studies because it does not rely on incomplete official statistics and instead uses direct measurement approaches that are feasible in the current Indian context: survey data from a representative sample of public and private health facilities that provide abortions and national data on sales of MMA (see Survey Methodology).
Although knowing the number of abortions performed is important because it helps us understand the magnitude of this public health issue (and because it allows for indirect estimation of unintended pregnancy), information on how and where abortion takes place is equally important for policy making and planning. Scant data are available that describe the provision of induced abortion services in Bihar. Government statistics from 2010 show there were only 146 public and registered private facilities approved for provision in the state to serve a population of 23 million women of reproductive age; however, this number is an undercount because it excludes facilities that do not report their services.33,34 A community-based study conducted in all 38 districts of Bihar found that, in 2010–2011, there were 334 facilities providing abortion services, 79% of which were privately owned.10 The same study suggested that more than 90% of all induced abortions occurring between April 2010 and February 2011 were not reported or counted in any official statistics.
Few data exist on the methods women in Bihar use to terminate pregnancies outside of health facilities. However, studies conducted in various parts of the country show these methods range widely in effectiveness and safety. They include MMA, ayurvedic and homeopathic preparations procured from chemists and informal vendors,35,36 and home remedies.37,38
In 2011, in recognition of the need to increase access to safe abortion to reduce maternal morbidity and mortality, the government of Bihar launched Yukti Yojana, a program for accrediting and supporting private health care facilities to provide abortion in the first trimester (i.e., in the first 12 weeks of pregnancy) and postabortion care services.39 Through this program, facilities fulfilling accreditation requirements are eligible to provide abortion services free of charge to low-income women, and providers are reimbursed by the state government for these services. At the time this report was written, 238 sites had applied for accreditation and 70 sites had been accredited.40
Provision of Abortion-Related Services
Women’s access to safe, legal abortion-related services depends to a large extent on whether nearby facilities provide such care and what specific types of services are available. These topics are discussed below, and additional details are available in the fact sheet, “Provision of abortion and postabortion services in Bihar, 2015.”42
In 2015, an estimated 2,834 facilities in Bihar were providing any abortion-related services (induced abortion, postabortion care† or both types of services); 629 facilities (22%) were public and 2,205 (78%) were private (Table 2). Although 59% of facilities reported offering both abortion and postabortion care, 6% restricted their services to the former and 34% to the latter. The majority of public hospitals (71%) and CHCs (56%) offered both abortion and postabortion care, whereas most PHCs (79%) offered only postabortion care. Overall, 94% of facilities providing any abortion-related services offered postabortion care and 66% offered induced abortion.
Sixty-nine percent of facilities offering abortion-related services in Bihar were located in urban areas, although only 13% of the state’s female population resides in these areas.27 Fewer than 10% of hospitals—the facilities best equipped to handle severe complications or later-term abortions—were located in rural areas. Among facilities offering any abortion-related care, 58% in rural areas were private, compared with 87% in urban areas (Appendix Table 1).
Among the estimated 2,127 public facilities in Bihar, only 30% reported offering induced abortion, postabortion care or both services, whereas 70% offered neither service (Figure 1). The proportion providing these services varied widely by facility type: Some 77% of public hospitals, 59% of CHCs and 23% of PHCs provided any abortion-related care in 2015. We cannot give this breakdown for private facilities because our list included mainly those providing abortion-related care.
Among all public and private facilities that offered induced abortion services in 2015, 75% offered both MMA and surgical methods, 11% offered only MMA, and 14% offered only surgical methods (Appendix Table 2). A higher proportion of private facilities (79%) than public facilities (52%) offered both types of methods.
Facilities not offering induced abortion
Among facilities whose abortion-related services were restricted to postabortion care, the reasons reported for not offering induced abortion varied according to public or private ownership. Public facilities offering only postabortion care commonly cited lack of trained staff (81%), lack of equipment or supplies (63%) and lack of space (16%) as reasons for not offering abortion (not shown). In contrast, private facilities offering only postabortion care most commonly reported lack of registration to provide abortion (56%), religious or social reasons (42%) and lack of equipment or supplies (32%); some (19%) reported lack of trained staff.
Availability of postabortion care
Because medical complications can occur at any time of day or night, an important indicator of access to postabortion care is whether a facility is open 24 hours a day, seven days a week. In Bihar, among facilities providing postabortion care in 2015, 73% (including more than 70% of public hospitals, CHCs, private hospitals, nursing and maternity homes, and private clinics) offered care 24-7 (Appendix Table 3). More than half of public facilities (58%) providing postabortion care offered it around the clock, compared with more than three-fourths (78%) of such private facilities. Availability of 24-7 postabortion care was greater among facilities offering these services in urban areas (81%) than in rural areas (56%).
Induced Abortion Services Provided in Facilities
By gathering data from a sample of health facilities providing abortion, we were able to estimate the total number of facility-based abortions provided in Bihar in 2015. Knowing what methods facilities use is an important part of understanding the abortion landscape, as nearly all surgical abortions—as well as a portion of those using MMA—are provided at facilities.
An estimated 185,200 induced abortions were provided in health facilities in Bihar in 2015 (Figure 2 and Appendix Table 4). This estimate was derived by summing the weighted number of abortions provided by each facility type that year. (Abortions performed outside of health facilities are discussed later in this report.) The majority of terminations provided by NGOs are not included here because we obtained those data from administrative sources and not through our facility-based survey; therefore, we have less detail on those abortions. Only 8% of all facility-based abortions occurred in the public sector: Nearly two-thirds (65%) of these were provided in hospitals, 14% in CHCs and 21% in PHCs. The vast majority—92%—of facility-based induced abortions in 2015 took place in the private sector. Of these, 62% were provided in nursing and maternity homes, 32% in clinics and 7% in hospitals.
On average, each public hospital provided about 90 induced abortions in 2015; CHCs provided 60 and PHCs provided 30. Private hospitals had a caseload of 90 abortions, while private nursing and maternity homes and clinics had higher average caseloads of 100 and 120, respectively.
Nearly half of induced abortions provided in private-sector facilities in Bihar—45% of all facility-based abortions in the state—were performed in facilities that HFS respondents reported as not being registered to offer that service. Of these, 10% took place in unregistered private hospitals, 67% in unregistered nursing and maternity homes, and 23% in unregistered private clinics. That a sizeable share of private-sector abortions were performed at unregistered sites may imply that facilities are encountering barriers to registration.
Timing of abortion and facilities’ gestational limits
Nearly all (91%) of the facility-based induced abortions taking place in Bihar in 2015 were performed in the first trimester (i.e., the first 12 weeks of gestation): 52% in the first seven weeks and 39% in weeks 8–12 (Appendix Table 5). Only 9% of abortions provided in facilities occurred beyond 12 weeks.
At most types of public and private facilities, 88–97% of induced abortions occurred in the first trimester. PHCs and private clinics had a higher proportion of abortions at this gestation than other facility types. At CHCs, on the other hand, the proportion of abortions taking place in the second trimester (13–22 weeks’ gestation; 28%) was higher than that in other types of facilities.
Although abortion is legally permitted up to 20 weeks’ gestation in facilities approved for second-trimester abortion, many set earlier gestational limits. Among facilities providing abortion in Bihar, about three-quarters (73%) reported offering terminations in the first trimester only, including 72% of public hospitals, and two-thirds of both private hospitals (66%) and nursing and maternity homes (67%; Figure 3).‡ Across facilities, the proportion offering abortion services beyond that gestation was highest among CHCs.
Among facilities offering abortion only in the first trimester, the most commonly cited reasons for not offering second-trimester terminations were fear of providing sex-selective abortions (60%), lack of registration for abortion provision at that gestation (44%), lack of blood storage facilities (40%) and lack of trained staff or providers (31%; not shown). The proportions reporting reasons related to sex-selective abortion and registration were higher among private facilities than among public facilities, while the proportions lacking trained providers, blood storage facilities, and equipment and supplies were higher among public sites. Inadequate infrastructure was cited by 39% of public facilities not offering second-trimester abortions but by only 7% of corresponding private facilities. The proportion citing lack of trained providers as a reason for not providing terminations in the second trimester was typically larger among lower-level facilities (CHCs, PHCs and private clinics) than higher-level facilities.
Abortion methods used in facilities
Among facilities that provided induced abortion in Bihar in 2015, the majority (75%) offered both MMA and surgical procedures. However, facilities offering abortion often reported using methods that are not in line with best practices. World Health Organization (WHO) guidelines recommend the use of MMA or vacuum aspiration for most abortions; dilatation and evacuation (D&E) is recommended in situations in which the other methods are contraindicated (typically in the second trimester), and dilatation and curettage (D&C) is no longer recommended as an abortion method at any gestation.43
Among abortions occurring in health facilities in Bihar, 27% were performed using MMA (Figure 4). The proportion using MMA was highest at PHCs and private unregistered clinics: In both types of facilities, this method was used for nearly two-thirds of abortions (Appendix Table 6). Forty-three percent of facility-based abortions were performed with either manual or electric vacuum aspiration (MVA or EVA), which are the least invasive surgical methods, and 31% involved more invasive surgical procedures: D&C or D&E. We have grouped these latter two methods together because providers may use D&C as a generic term for surgical abortion; therefore, individual proportions may not be reliable. §44
The share of abortions performed using D&C or D&E varied little according to whether facilities were public (29%) or private (31%). These methods together were more commonly used than vacuum aspiration at PHCs, private unregistered nursing and maternity homes, and private unregistered clinics. The proportion of abortions using D&C or D&E in PHCs was roughly the same as that in public hospitals and CHCs (27–30%). Given that only 9% of facility-based abortions occurred after the first trimester, we can infer that, on the whole, providers in Bihar are relying on more invasive and riskier abortion techniques than they should be at early gestations.
Barriers to seeking safe abortion services
When asked what barriers women face when seeking safe abortions, HFS respondents reported fear of stigma (71%), cost of services (56%), lack of information about safe services (41%), distance or transportation difficulties (32%), and objections from a family member (31%; not shown). Eighty percent felt that women face at least three barriers to obtaining a safe abortion. Respondents from public and private facilities generally had similar perceptions of the barriers women face.
Women seeking abortions at health facilities may encounter a different set of barriers, and these are typically related to the facility or staff being unable or unwilling to provide the abortion under some circumstances. In Bihar, 87% of facilities that provide abortion reported turning away at least one woman seeking a termination in the year preceding the survey; among this group of facilities, 79% cited capacity-related reasons (provider not available, MMA not available or facility gestational limits exceeded; not shown). In addition, staff at health facilities providing abortion services either may not be well informed about the conditions under which termination is legally permitted or may have social or personal reasons for choosing not to offer it to some women. For example, among the facilities that reported having turned away at least one woman seeking an abortion, 25% did so because women did not obtain consent from a partner or other family member, and 29% did so because they were unmarried or had no children, or because the provider considered them to be too young.
Provision of Postabortion Care
When induced by prescription drug or performed surgically by a trained provider under hygienic conditions, abortion is very safe. However, because abortions occur in a variety of settings in Bihar—including at registered and unregistered health facilities, as well as outside of the health care system—the safety of the method used and the incidence of complications vary. In the Health Professionals Survey, key informants said that, particularly in rural areas, some women resort to methods such as herbal solutions, homeopathic medication, abdominal massage or pressure, and insertion of solid or sharp objects into the vagina, cervix or uterus.
It is important to assess the extent to which unsafe abortions are occurring, as well as the incidence of complications, but doing so is difficult because unsafe abortion is often clandestine and is not captured in official reporting. Representative estimates from the HFS of the amount of complication-related care provided by health facilities offer a good indicator of the incidence of unsafe abortion, although it is an underestimate because it excludes women who need facility-based care and do not receive it. This underestimate is partly offset because some women or providers may misdiagnose bleeding, which is part of the normal process after a medication abortion, as an abortion complication.45 These women are included in providers’ reports as having had a complication, although their abortion likely would have been completed safely without the additional medical care.
According to 2015 HFS data, about 360,500 women in Bihar were treated for complications that resulted from either induced abortion or miscarriage (Table 3); this care took place in the estimated 2,652 public and private facilities providing postabortion care in the state. Of these women, we estimated that 299,800 were treated for complications resulting from induced abortion, and 60,700 were treated for complications related to miscarriage (discussed in greater detail later in the report). Among all patients treated for complications, 21% obtained treatment in public facilities, while the remaining 79% went to private facilities. The number of women treated for complications at public facilities was about four times the number who obtained induced abortions at these facilities.
On average, each facility providing postabortion care treated 140 women for complications of induced abortion and miscarriage in 2015. The average annual postabortion care caseload was similar at private facilities (140 women treated per year) and public facilities (130). Among public facilities, hospitals treated the highest number of cases (330). Private nursing and maternity homes accounted for the largest proportion of care for complications: Some 57% of patients, or 206,500, got care in these facilities in Bihar in 2015.
Types of complications treated
The types of medical problems women presented with help us understand how severe their complications were and what interventions and medical resources they may have needed. Knowing women’s diagnosis on admission also helps to assess the extent to which women actually needed treatment, given the high overall level of MMA use (discussed later in this report) and the potential for normal bleeding to be misdiagnosed as a complication.
Survey respondents were asked to estimate the proportion of women with each of the major types of complications, among all women treated for complications related to either induced abortion or miscarriage in their facility. Because women may experience more than one type of complication, multiple responses were permitted. In Bihar, incomplete abortion resulting from MMA was the most commonly reported complication, and HFS respondents estimated that it affected 51% of women obtaining care for complications (Figure 5 and Appendix Table 7). Incomplete abortion from other methods was the second most commonly reported complication type (32%). The third most common diagnosis among these patients was prolonged or abnormal bleeding (30%), which can result from either abortion or miscarriage.
Treatment for incomplete abortion resulting from MMA and prolonged bleeding are likely to be highly overlapping categories, and estimates of the proportion of women treated for these types of complications likely included many cases in which abortions would have been safely completed without need for further intervention, had women been given the correct information and counseling. An unknown proportion of women received needed treatment for incomplete abortion because of incorrect use of this method, but it is likely that this proportion was small, given that MMA using a combination of misoprostol and mifepristone, when administered correctly and within a nine-week gestational limit, is 95–98% effective.46
Relatively small proportions of women were estimated to have been treated for severe complications, such as infection of the uterus and surrounding areas, sepsis, shock or physical injuries (e.g., perforation or lacerations)—all of which were assumed to have resulted from induced abortion. However, these small proportions represent tens of thousands of women in Bihar experiencing these severe complications each year. For example, among women treated for complications of induced abortion, an estimated 16% of patients—48,000 women—received care for infection of the uterus or surrounding areas (the most commonly treated severe complication) in 2015. Nine percent of patients treated for abortion complications received treatment for physical injury, 5% for sepsis and 4% for shock. It is not possible to estimate precisely how many women were treated for severe complications overall, as there is some overlap among the categories. The majority of these severe cases likely originated among the group of women having nonfacility abortions using methods other than MMA.
Number of women treated for postabortion complications
By applying an indirect approach to estimating the number of women who were treated in health facilities for later-term miscarriages,** we were able to estimate the number treated specifically for complications of induced abortion. Approximately 299,800 women were treated for induced abortion complications in health facilities in Bihar in 2015 (Table 4). This means that 24% of all women terminating pregnancies were treated in health facilities for complications, equivalent to an annual rate of 11.8 women treated per 1,000 women aged 15–49. The induced abortion complication treatment rate in Bihar is lower than the rate for Pakistan (13.9 per 1,000 in 2012),8 but is higher than rates found in other South Asian countries with available data: Nepal (8.2 in 2014) and Bangladesh (6.1 in 2014).6 Among these four countries, abortion is most restricted in Pakistan, which may contribute to that country’s higher complication treatment rate. However, it is important to note that the treatment rate does not necessarily directly correspond to abortion safety. Depending on the context, low treatment rates could represent either low complication rates or insufficient access to postabortion care.
As mentioned previously, estimates may include some cases in which normal bleeding associated with MMA was misidentified as a complication. If all cases of postabortion care to treat MMA-related incomplete abortion are assumed to be cases in which the abortion would have gone to completion without further intervention, the treatment rate for induced abortion complications that truly needed facility-based care would be 4.6 per 1,000 women annually, a total of 115,000 women. This rate is purely hypothetical but helps to express the lower limits of the complication rate. The true rate of induced abortion complications requiring treatment is likely to be higher than this hypothetical rate but lower than the overall estimate of 11.8 cases per 1,000 women aged 15–49.
Incidence of Induced Abortion and Unintended Pregnancy
Abortion incidence is an important indicator of women’s need for safe termination services, and it sheds light on women’s contraceptive behavior and their experience of unintended pregnancy. The UPAI study provides a comprehensive estimate that reflects the full range of methods and providers that women use in Bihar. In addition to estimating public- and private-sector abortion provision in health facilities, it estimates abortions in the informal sector, capturing those undertaken via MMA provided by chemists and informal vendors, those performed by untrained providers and those induced by women on their own (see Incidence Methodology). Our estimation methodology relies on health sector information whenever possible to avoid the high level of stigma-related underreporting that generally occurs in household surveys that directly ask women about their abortions.47,48 More detailed information on our estimation methodology is available online (see “supplementary materials” at https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30453-9).
We estimated the number of induced abortions in Bihar in 2015 to be 1.25 million and the abortion rate to be 49 abortions per 1,000 women of reproductive age (Table 5). The rate for Bihar is similar to the rate the UPAI study estimated for Gujarat (48),49 while higher than the rate for Tamil Nadu (33)50 and lower than rates in Madhya Pradesh (57),51 Uttar Pradesh (61)52 and Assam (66).53
In Bihar, roughly 194,300 induced abortions in 2015—16% of abortions in the state—took place in facilities.*† As stated previously, about three-quarters of these were performed using surgical methods and one-quarter using MMA. The majority of facility-based abortions took place in private facilities (170,400, or 88%), and few in public facilities (slightly less than 8%) and NGO facilities (5%); both surgical and medical abortions followed a similar distribution by facility type.
MMA obtained outside of the formal health system accounted for an estimated 992,100 induced abortions—79% of all induced abortions in Bihar in 2015—and they occurred at a rate of 39 per 1,000 women of reproductive age. These MMA users purchased the drugs directly from chemists or other informal vendors, either without a prescription or with a prescription from a private physician who did not work at a facility covered by the HFS.
Another 64,500 abortions in 2015 were not performed in facilities and did not use MMA. These terminations, which represent 5% of all induced abortions in Bihar, likely encompass the most unsafe methods performed by quacks and other untrained providers and by pregnant women themselves. They may also include some surgical abortions performed by trained professionals outside of the facilities covered by the HFS.
Characteristics of women having an abortion
Because the HFS was not designed to capture information on the characteristics of women having abortions, we rely on 2015–2016 survey data from the NFHS-4 to ascertain the profile of this group. Among the 13,567 women aged 15–49 in Bihar who reported that their last pregnancy was in the three years before the survey, only 188 reported that that pregnancy ended in abortion (data not shown).27 This translates into an implausibly low 1.3% of all pregnancies terminated and a rate of only 2.4 abortions per 1,000 women each year. As noted previously, these data are problematic because women tend to underreport their abortions when interviewed. In addition, pregnancy data in the NFHS-4 is almost exclusively for married women, in part due to stigma surrounding sexual activity among unmarried women. Given the apparent high level of underreporting, women who report having an abortion may not accurately represent all women having abortions. Nevertheless, we do not have reason to believe that some women are more likely than others to underreport abortion, so household survey data remain a useful source of information on the demographic and socioeconomic characteristics of the small group of women who reported having had an abortion in this survey.
Among women in Bihar who reported having had an abortion in the past three years, 84% lived in rural areas (Appendix Table 8).27 Sixty percent were categorized as belonging to the socioeconomically disadvantaged castes collectively designated Other Backward Class. These proportions reflect the distribution of Bihar’s general population of reproductive-age women according to these characteristics.
Nearly all women who reported having had an abortion were already mothers at the time of the survey. About half (51%) had three or more children, and a third (33%) had two children. Fifty-nine percent had been married for 6–15 years, and 18% for 16 years or more. By age-group, the greatest proportion of women having an abortion were 25–29 years old (43%).
Among women who reported having had an abortion, 34% had no schooling, 16% had 1–5 years of schooling, 34% had 6–11 years, and 16% had 12 or more years. These women were more educated than the general population of women of reproductive age, 48% of whom had no schooling.
Incidence of unintended pregnancy
Unintended pregnancy is the precursor to most induced abortions and a key indicator of the need for modern contraception and for the services and information that support effective use. Unintended pregnancies may indicate that women are not using a method, are using the method inconsistently or incorrectly, or are using a relatively ineffective traditional method. Understanding the level of unintended pregnancy in Bihar helps us ascertain the extent to which women need contraceptive and abortion services.
We determined there were approximately 4.7 million pregnancies in Bihar in 2015. Of these, 52%—or 2.46 million—were intended, and the remaining 48%—or 2.26 million—were unintended (Figure 6). More than half (55%) of unintended pregnancies ended in an abortion.
Bihar’s total pregnancy rate was 187 pregnancies per 1,000 women of reproductive age in 2015 (Table 6). The intended pregnancy rate was 97, and the unintended pregnancy rate was 89. There were 81 planned births and 29 unplanned births per 1,000 women aged 15–49.
The high level of unintended pregnancy highlights the need for improved voluntary and comprehensive contraceptive services for all women of reproductive age—as part of the continuum of care, including in the context of postabortion and postpartum services—to prevent and address unintended pregnancy and unplanned childbearing.
Conclusions and Recommendations
Some of the UPAI study findings are encouraging and provide evidence of gains in regard to the provision of abortion services in Bihar. For example, most facilities that provide abortion care offer both MMA and surgical abortion, indicating these facilities can tailor care to each case. In addition, the large majority of facilities that offer abortion-related care also report providing contraceptive services,42 thus contributing vitally to women’s continuum of sexual and reproductive health care. However, our findings also highlight several areas of women’s sexual and reproductive health urgently needing attention in Bihar. The incidence of abortion and related indicators—including high levels of abortion complications—reflect the need for thorough review of the state’s ability to meet the needs for safe abortion services and postabortion care. In addition, the substantial level of unintended pregnancy indicates a need to improve contraceptive services.
Moreover, high rates of unintended pregnancy and abortion not only are indicative of women’s inadequate access to and ineffective use of modern contraceptives, they also stem from gender inequity—in families and in society more broadly—that restricts women’s access to information and services, and may compromise their ability to negotiate contraceptive use when they do not desire a pregnancy. Despite recent trends toward increased age at first marriage, early marriage remains common in India; women and girls continue to face gender discrimination; and access to sexual and reproductive health services, including safe abortion, is limited. Addressing the root causes of son preference and other forms of gender discrimination is critically important and should be pursued hand in hand with efforts to improve access to safe abortion services.
Below, we make recommendations aimed at increasing and improving the provision of abortion-related and contraceptive services. We also address the need to improve collection of data on abortion going forward.
Our data reveal several areas in which services must be expanded to meet women’s needs.
Coverage and location of services. Only 31% of all health facilities offering any abortion-related services are located in rural areas, where 87% of Bihar’s women of reproductive age reside. Thus, access to induced abortion care and services to treat postabortion complications is extremely limited for rural women, particularly those who are poor.
PHCs are the first—and often the only—point of contact poor and rural women have with the health system. Yet only 5% of these facilities offer induced abortion and just 22% offer postabortion care. This highlights the need to expand service provision by trained providers at PHCs to include both early abortion using MMA and care for abortion complications. One way to improve access to abortion services in underserved areas is to implement a job rotation system whereby trained providers can work in hard-to-reach areas on a temporary basis to ensure that coverage is both available and consistent.
Addressing major barriers to abortion provision. Provision of induced abortion is low even among public facilities that would usually be expected to provide that service: Two-thirds of CHCs (67%) and 44% of public hospitals do not offer abortion. One of the key reasons reported in the HFS for why public health facilities do not provide abortion is the lack of equipment and supplies. Adequate funding should be allocated through state Programme Implementation Plans to provide these items on a regular basis and ensure they reach the facilities, and the budgeting system should be simplified to facilitate its accurate use.
A major barrier among private facilities is the lack of registration to provide abortion and the difficulties involved in obtaining such approval.65,66 Steps are needed to ensure that the District Level Committees responsible for site approval are in place and functional. In addition, accelerated registration should be implemented for private facilities seeking approval to provide abortion using MMA only. Other strategies to streamline the process include setting up online application options, as has been done in Uttar Pradesh.67 Lack of trained providers, another major barrier to provision for both public and private facilities, is discussed below.
Provision of free or affordable services. The majority of women obtaining abortions do so outside of the public sector, where they presumably pay out of pocket for services. However, the costs associated with private-sector care are likely a barrier or a burden for many women. It is important to conduct research that collects women’s views on the accessibility and acceptability of current abortion-related services and their reasons for seeking care outside of the public sector. Simultaneously, the health system should work to ensure that free or low-cost abortion services in this sector are confidential, youth friendly and nonjudgmental. The financial accessibility of services in Bihar can be increased by strengthening and expanding the Yukti Yojana program, which helps private providers become accredited to provide free first-trimester abortion and postabortion services to poor and low-income women.
Provision beyond the first trimester. Only one-quarter of facilities that provide abortions offer them in the second trimester, and although these abortions are less frequently requested than earlier terminations, their availability is vital. The most vulnerable women—including those who are poor, young, unmarried or widowed, and those who are victims of sexual violence—may be most likely to experience delays in seeking abortion services because of transportation issues, social taboos and lack of agency.68 These women, along with those who develop severe health complications or who discover fetal anomalies, are the most likely to be negatively affected by the lack of access to abortions at later gestations. Special efforts should be made to ensure that an adequate distribution of public- and private-sector facilities offer second-trimester abortion services.
Also threatening women’s access to safe abortion generally, and second-trimester abortion specifically, is the country’s reaction to the adverse sex ratio. The government’s response, as part of implementation of the PCPNDT Act, has been to restrict abortion services and strictly regulate and monitor providers. Providers have reported that unannounced inspections and harassment by authorities have prompted them to stop providing abortions, especially in the second trimester.69 Increased communication between those implementing the law and community-level stakeholders is needed to clarify that not all second-trimester terminations are for the purpose of sex selection, to communicate that women are legally entitled under certain circumstances to second-trimester abortion, and to dispel misconceptions about the legal status of abortion. The MoHFW issued guidance in 2015 for ensuring access to abortion services and addressing gender-biased sex selection, and these guidelines should be fully implemented at the district and provider levels.70
Training providers and staff
HFS data indicate that abortion provision in Bihar suffers from a lack of qualified providers, and training may be inadequate for those currently providing services. Lack of trained staff is the primary reason public facilities gave for not offering induced abortion services. Expanding the number of qualified, certified abortion providers will require improving access to training and certification for allopathic doctors (those holding MBBS degrees) working in both the public and private sectors. Approving the proposed amendment to the MTP Act that would allow nurses and ANMs, as well as practitioners trained in Indian systems of medicine with recognized qualifications, to provide MMA would further help address this shortfall in providers.
Second, lack of training is likely a major reason for the overuse of invasive surgical abortion techniques (particularly during the first trimester) observed in the HFS and other sources.71 Providers should be routinely updated on WHO and national guidelines for abortion provision. In addition, they should be trained (or retrained, as necessary) in recommended techniques, especially MMA and vacuum aspiration.
Third, staff at health facilities sometimes turn away women seeking abortions for reasons that do not accurately reflect legal restrictions or the facility’s capacity to provide abortion. Providers who deny services because they perceive a patient as being too young or because she is not married or does not have family members’ consent may be acting on bias rather following guidelines. Regular efforts should be made to ensure that health care providers and other facility staff do not impose unnecessary limitations on abortion provision.
Lastly, social stigma related to abortion creates a barrier to the use of safe services, even where they are offered. This barrier is likely to negatively affect certain vulnerable groups more than other women; unmarried women, for instance, likely face strong stigma because of taboos against premarital sexual activity.71 Health care providers can help to protect their clients from the potential social costs of seeking an abortion by offering private and confidential services. This calls for training of public-sector staff involved in providing abortions services on so-called soft skills, such as respecting women’s privacy and maintaining nonjudgmental attitudes. Accredited social health activists (ASHAs) and ANMs should be priority recipients of such training because they are often the first point of contact for women seeking abortion. In addition, facilities can work to increase the confidentiality of health care visits, including by conducting consultations behind privacy screens, and adopting protocols for speaking to women about sensitive or taboo issues to reassure them that their identity is being protected.
Educating the public about induced abortion
Providers report that some women seeking abortion may have gaps in their understanding about the circumstances under which it is permitted and where to obtain safe and legal services. Reaching communities with social awareness programs will require working on multiple fronts and engaging a variety of community-based groups. Strategies could include the following:
- Educating providers in order to counteract misinformation about the legal status of abortion.71
- Orienting ASHAs and ANMs on abortion-related information. Although these health workers do not perform abortions, they are in frequent touch with the community and have the opportunity to inform women who want to terminate a pregnancy on the law and where to obtain safe services.
- Displaying information at public health facilities that educates visitors about the legality of abortion, safe methods of abortion, and the risks involved in using unsafe methods, going to unqualified providers or using MMA incorrectly.
- Including information about abortion during all types of sexual and reproductive health visits. This would help to reach the large proportions of women who have an institutional delivery and make prenatal care visits, as well as those obtaining contraceptive counseling.
- Actively disseminating the Government of India’s mass media campaign Making Abortion Safer, which was aired on television channels nationally.72 Efforts could be made to tailor its messages to specific target audiences.
- Offering culturally sensitive sexuality education—both in and out of school settings—to ensure that young people are provided with age-appropriate and accurate information related to all aspects of their sexual and reproductive lives, including information about contraception and abortion.
Improving MMA services
MMA is safe and highly effective when the correct regimen is followed, and increased provision of this method, both in health facilities and in nonfacility settings, has improved access to abortion care. It has also likely reduced severe abortion-related morbidity: Available data on MMA drug distribution indicate that its use has been replacing the use of traditional and less safe methods of abortion.73 Continuing to expand MMA provision would likely lead to further reductions in abortion morbidity.
At the same time, the implication in the HFS data that normal bleeding associated with MMA is sometimes misdiagnosed as a complication suggests that women who obtain MMA outside of facilities may be inadequately informed about the method or may have been given incorrect advice to seek treatment in facilities as soon as bleeding begins. In addition, the safety and effectiveness of MMA depend to some extent on the quality of the information given and the user’s adherence to the protocol.
Some strategies to facilitate proper use of MMA include ensuring combipacks have clear and simple instructions in multiple languages, as well as pictorial instructions for women with low literacy. The inserts should describe the regimen and expected symptoms, and should indicate where to go in case of complications. In addition, it may be beneficial to set up a telephone helpline to provide information to users, to ensure that women who use MMA in a nonfacility setting can do so safely. The helpline number could be printed prominently on MMA packaging and displayed at pharmacies.
Because the great majority of abortions in Bihar—four out of every five—use MMA obtained outside of a health facility, there is a particular need to find out more about the women who obtain MMA this way, their reasons for not using facility-based services, the type of provider they go to and their knowledge of the regimen (e.g., awareness of protocols and normal bleeding). In addition, we need to know more about the extent to which women who seek treatment for complications after taking MMA outside of a facility experience complications that require treatment and the costs they incur.
Improving access to and quality of postabortion care services
Many of the strategies that will improve abortion services will have the added benefit of improving postabortion care. For instance, increased training in abortion techniques will also bolster the provider skills needed for postabortion care; training about abortion law, countering stigma and providing confidential services will improve providers’ abilities to give high-quality care to patients experiencing abortion complications; and strategies to increase public-sector provision of abortion and postabortion care will go hand in hand.
Other steps can be taken to specifically address the need for improved postabortion care. HFS data show that most complications reported in 2015 were relatively minor, such as bleeding and other non–life-threatening complications resulting from use of MMA without professional guidance. With proper training, relatively low-level medical staff can address these types of complications, and specialized training of a wide provider base in treating these complications would greatly increase access to treatment. In addition, a small but notable proportion of women experience severe complications, so providers should also be trained in best practices for treating infection, sepsis, shock and physical injuries caused by unsafe abortion.
Ensuring availability and correct use of contraceptives
Levels of unmet need for contraception are considerably higher in Bihar than in India as a whole, and as a result, unintended pregnancy and unplanned childbearing persist in the state. Using this evidence, the state should continue to promote access to contraception but also take additional steps to ensure women and couples are able to meet their fertility goals, including by offering a range of contraceptive methods and improving counseling on how to use them correctly and consistently. The Government of India already recognizes this need and has included it in its postabortion family planning guidelines.74 The rollout of these guidelines should be prioritized to strengthen women’s access to postabortion contraceptive care.
Although nearly all facilities reported in the HFS that they offer contraceptives to abortion clients and postabortion care patients,42 uptake of modern methods (aside from female sterilization) is still very low. This may signal an unmet need for reversible modern contraception for women who want to delay childbearing. It is important to ensure comprehensive, high-quality contraceptive counseling that addresses women’s concerns about use and helps them find the method that best suits them. Failure to provide contraceptive counseling to this segment of the population is a missed opportunity to help women prevent subsequent unintended pregnancies and abortions.
Improving data collection
To obtain a more complete picture of abortion and postabortion care—and thus improve the government’s ability to address gaps in and barriers to abortion-related services—the MoHFW needs to expand its data collection. Doing so will require making sure the Health Management Information System more comprehensively captures abortion-related services provided in public and registered private facilities. Improving the process for registering private health facilities that provide only MMA and meet requirements for providing this service would create a formal channel for such facilities to report the services they provide, improving the overall coverage of official abortion statistics. Both public and private providers would need to be sensitized about the importance of keeping records on abortion data for reporting to the MoHFW and how to do so correctly and confidentially.
Mechanisms should also be put in place to periodically monitor the quality of abortion services at all levels of public and private facilities. Improving the documentation of abortion service statistics would allow the government to understand on a consistent basis the quality and scope of the services being provided and to gauge the need for improvement or expansion.
The way forward
Improving and expanding abortion and postabortion care is an important step toward bettering overall measures of sexual and reproductive health in Bihar. Greater sexual and reproductive health, in turn, improves the status of women and the well-being of individuals, families and communities. Action must be taken on multiple fronts. Our study’s findings provide support for an array of policy and program actions, and for current and ongoing efforts to increase access to and quality of abortion-related services. In addition, our estimates of unintended pregnancy highlight the need for comprehensive contraceptive services—as part of the continuum of care for all women of reproductive age and, specifically, as part of postabortion and postpartum services—to prevent and address unintended pregnancy and unplanned childbearing. Whatever steps are taken must include and prioritize the needs of disadvantaged groups, including poor and rural women, ensuring that no groups are left behind.
*In 2010, the MoHFW’s Comprehensive Abortion Care Training and Service Delivery Guidelines for providing comprehensive abortion care indicated in a footnote that MMA up to 63 days’ gestation is safe.11 However, amendments to the MTP Act that would reflect this modification are still awaiting passage in Parliament.
†Unless otherwise specified, the term postabortion care refers to care related to complications of both abortion and miscarriage.
‡Data based on responses to a question about facility capacity, not on actual caseloads.
§Providers reported 22% of women obtaining facility-based abortions underwent D&C and 8% underwent D&E.
**From clinical studies, we know the proportion of miscarriages that are not fetal losses but that occur in the second trimester (i.e., at 13–22 weeks’ gestation). Given that women experiencing these types of miscarriages need care, but not all of them are able to get it (and are therefore not captured in the HFS), we estimate that the probability of getting care for a second-trimester miscarriage is equal to the probability of delivering in a facility. The resulting estimated number of women seeking care for complications related to late-term miscarriages was then subtracted from the total number of women seeking care for complications.
*†These estimates for facility-based abortions differ slightly from those cited in earlier in the report because these include official statistics from NGO facilities in addition to public and private facility estimates derived from the HFS.
SURVEY METHODOLOGY FOOTNOTES
a. Throughout this report, the text and figures show proportions as whole rounded numbers, while the tables show them rounded to one decimal place. Thus, there are occasional slight discrepancies between text, figures and tables (for example, the original value 46.47 would appear as 46 in the text but 46.5 in the tables).
b. Public facilities were grouped into hospitals (including rural, district/civil, sub-divisional, municipal, tertiary, railway, Employees’ State Insurance Corporation and refinery hospitals, and public medical colleges), CHCs (including first referral units and non–first referral units) and PHCs (including those that are and are not open 24-7, and block PHCs). Private facilities were grouped into hospitals (including multispecialty hospitals, specialized hospitals and private medical colleges), nursing and maternity homes, and clinics.
c. We first converted the data to annual caseloads, multiplying caseloads that were reported for the past and average month by 12, and combining these with responses reported for the past and average year. We then took the average of the number of induced abortions reported in the past and average year as the best estimate of the total annual number of pregnancies terminated in each facility. By applying sample weights, we obtained total estimates at the state level, by type of facility and ownership.
d. A few NGOs were included in the HFS private facility sample. We cross-checked these with the compiled list of NGOs to ensure there were no duplicates.
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