Transcript Exploring the Transformative Potential of Medical Abortion

Making Abortion Safe in Asia: Singularity of
Focus
Priya Nanda
International Center for Research on Women (ICRW)
APCRSH, Beijing, October 19th , 2009
Abortion Scenario in Asia
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High fertility rates
High unmet need for contraception
High rates of unwanted pregnancies and abortions
Unsafe abortion account for about ten percent of MMR
Stringent Laws/Policies
Inequitable coverage of service facilities & ‘legal’ providers
Limited information and choice around RH methods
Stigma of abortion
Tenets of the Rights-based Approach
– Sexual and reproductive rights, understood as private “
“choices,” are meaningless without enabling conditions
and public support.
– Individual and social dimensions of reproductive and sexual
rights can not be separated as long as there is gender
inequity.
– Application of rights needs cognizance of women’s and
girls’ realities. These include lack of resources and
information, inability to negotiate contraception, early
marriage, unmet need, violence and coercion, and unfair
burden of ‘bearing’ a son.
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Introduction of MA Pills in India
• Combination of oral Mifepristone (200 mg) followed by
Misoprostol (800 µgm)
• For gestation upto 9 weeks
• Approved in India in 2002
• MTP Act amended in 2003 to allow Medical Abortion (MA)
• Currently around 20 brands available
• Has transformative characteristics: easier access, safe, easy to
use, cost effective, non-invasive, expanded choice and offers
confidentiality
YET
Access to & use of MA pills limited
Women access a diversified provider base, both
within & outside the law
Providers accessed
– 43% Ob/Gynaecologists
– 29% Indian system of medicine i.e. BHMS/BAMS
– 14% General practitioners (MBBS)
– 8% Pharmacists
– 6% Nurses
Rational choices: Convenience/distance, familiarity, affordability,
confidentiality
What a woman need in choice of facility/provider
I went to the doctor (MBBS ,Private) since she was known to
me, she provided good services, explained everything and was
also near to my home. In case of any difficulty, it would be
convenient to go for follow-up visit. – 28 years old, Xth grade,
rural woman with 1 son
Women acknowledge positive and potentially
transformative attributes of MA
• Users articulate a sense of relief on complete abortion
• 1/3rd decided on their own to use MA
• Reported easy availability, affordability & privacy as key factors
• 82% had no significant side effects with use
• Some pain and bleeding within 12 hrs of taking drug but expected it
from some pre-procedure counseling
• Several needed privacy due to coercion or violence at home
Confidentiality unique to method choice
At the abortion centre I was told about two procedures of
abortion. The doctor told me that the medicinal procedure was
straight, simple and beneficial. .. no need to stay in the
hospital. There was absolutely no confusion in my mind. I
opted for medicinal procedure as it was readily available,
provider was nearby, it was affordable,…. was no need to stay
in hospital. Besides everything would be confidential.
Providers impact quality differentially
• Consent varied- mostly for self protection or inform
women of ‘risks’ rather than informed choice
• Varied regimen and protocol
• Not all are trained as not recognized by law
• Lack of gendered perspective –provider hierarchy
• Different emphasis on follow up or PAC
Limited knowledge about relevant laws &
guidelines
• >50% providers not aware of stipulations under MTP Act
• >50% providers unaware of guidelines for MA
• 2/3rd women unaware of MTP Act but aware of PCPNDT Act
due to heightened attention on sex selection
• No information in public domain because MA is Schedule H
drug (no OTC so no incentive to advertise publically)
Contrasting views about types of providers who
can prescribe & where
• Opposition to home use: Ob/Gy
• Opposition to OTC: All providers
• Bias towards surgical methods: Medical college professors
• Bias against MA for unmarried: Retailers
• Concept of ‘misuse’: use by unmarried women, taken OTC,
incorrect or incomplete regimen and lack of follow up
Respondents highlight ways to maximize MA’s
transformative potential
• Revise MTP Act
• Move MA into the public sector
• Diversify and potentially de-medicalize provide base
• Retailers to provide information, if no OTC
• Manufacturers should have ensure package inserts
• Introduce dedicated combination pack
Diversify Access
Women or their partners go to chemists tell them about the
unwanted pregnancy and ask for some pill .. More than half these
women / their partners do not come with any doctor’s
prescriptions. The chemists based on the knowledge garnered from
MR’s ..dispense drugs OTC. [Senior researcher/advocate]
Non-MBBS doctors should also be allowed to prescribe MA after
training. Also, if qualified nurses with midwifery training and 3
years of training can conduct deliveries then why not do MA or
even MVA? There are only 22,000 members of FOGSI and we
have a country of over 1 billion population. [Abortion Provider;
Senior FOGSI Representative]
Women Can Make Safe Choices
Women clearly do not go for
abortion mindlessly. They may be
repeat aborters but that is an
indication of their disempowerment
and the fact that they are unable to
negotiate contraception use. [Donor,
Subject Expert]
Abortion within a Rights-based Framework
• Access:
Options are available, affordable and clients
given choice
• Decision Making: Decision-making process is voluntary, non
coercive and informed.
• Services:
No stigma for all ages and unmarried. Provider
knowledgeable; Enhanced provider base with
updated training.
• Experience:
Good counseling services and client provider
interaction for follow up. Safe and complete,
ideally with PAC
• Environment:
Laws and policies actively create support
De-medicalized Access
A major barrier in my opinion is unawareness at every level,
women users, chemists and providers. Women or their partners go
to chemists tell them about the unwanted pregnancy and ask for
some pill to terminate it. More than half these women / their
partners do not come with any doctor’s prescriptions. The
chemists based on the knowledge garnered from MR’s ..dispense
drugs OTC. [Senior researcher/advocate]
I am not very comfortable with Pharmacists being the providers.
Women can calculate their LMP and gestational age but a pelvic
examination is important and if you get drugs OTC, who will do
this? I don’t agree that we should legitimize it just because it is
happening anyway. [Senior researcher MMA, Faculty Medical
College]
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It is a lucrative market of course. We have been working with hormones for long. We
felt it was a good opportunity and there was also the concern that the country is
burdened with the issue of inadequate FP and therefore unwanted pregnancies. There are
limited abortion services available. Secondly we felt that this is a good product which
has the potential to transform the way the condition is treated and how people handle
their lives [Senior Pharma Rep]
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There are variety of way in which stakeholder understand, articulate and assess misuse.
We do regular prescription surveys at random with a fixed no. of prescriptions from
doctors. If 20,000 anti-ulcer prescriptions are taken and Pantoprezol has 2000 then we
estimate a 1:12 ratio of actual sales. If we see a 2 lakh sale of Miso and estimate
backwards with a 1:12 ratio, we should see at least 15,000 prescriptions. The reality is
28 prescriptions. We suspect that either the doctors stock it themselves, there are OTC
sales or use by quacks and general practitioners”.