Unsafe abortion and abortion-related death among 1.8 million women in India

Abstract

IntroductionUnsafe abortion is a preventable cause of maternal mortality. While studies report high number of abortions in India, the population-level rates of unsafe abortion and their risk factors are not well understood. Our objective was to analyse the rates of and risk factors for unsafe abortion and abortion-related maternal death in India.MethodsWe conducted a secondary analysis of data from 1 876 462 pregnant women aged 15–58 years from nine states in the Indian Annual Health Survey (2010–2013). We calculated the rate of unsafe abortion and abortion-related mortality with 95% CI. Multivariable logistic regression models examined the associations of sociodemographic characteristics, health seeking behaviours and family planning with unsafe abortion and abortion-related mortality.ResultsThere were 89 447 abortions among 1 876 462 pregnant women in 2007–2011 (4.8%; 95% CI 4.8 to 4.9). Of these, 58 266 were classified as unsafe (67.1%; 95% CI 66.7 to 67.5). There were 253 abortion-related maternal deaths (0.3%; 95% CI 0.2 to 0.3). Factors associated with unsafe abortion: maternal age 20–24 years (adjusted OR (aOR): 1.13; 95% CI 1.09 to 1.18), illiteracy (aOR: 1.48; 95% CI 1.39 to 1.59), rural residence (aOR: 1.26; 95% CI 1.21 to 1.32), Muslim religion (aOR: 1.16; 95% CI 1.12 to 1.22), Schedule caste social group (aOR: 1.08; 95% CI 1.04 to 1.12), poorest asset quintile (aOR: 1.45; 95% CI 1.38 to 1.53), antenatal care (aOR: 0.69; 95% CI 0.67 to 0.72), no surviving children (aOR: 1.30; 95% CI 1.16 to 1.46), all surviving children being female (aOR: 1.12; 95% CI 1.07 to 1.17), use of family planning methods (aOR: 0.69; 95% CI 0.66 to 0.71). Factors associated with abortion-related deaths: maternal age 15–19 (aOR: 7.79; 95% CI 2.73 to 22.23), rural residence (aOR: 3.28; 95% CI 1.76 to 6.11), Schedule tribe social group (aOR: 4.06; 95% CI 1.39 to 11.87).ConclusionDespite abortion being legal, the high estimated prevalence of unsafe abortion demonstrates a major public health problem in India. Socioeconomic vulnerability and inadequate access to healthcare services combine to leave large numbers of women at risk of unsafe abortion and abortion-related death.

Risk factors for maternal mortality among 1.9 million women in nine empowered action group states in India: secondary analysis of Annual Health Survey data

“…In keeping with previous literature, under-reporting of early pregnancy deaths, particularly those arising from complications of abortion or deaths prior to detecting pregnancy, and of maternal deaths arising from indirect causes that might have been reported as deaths due to medical causes (ignoring the pregnancy state) could have led to an underestimation of maternal deaths. 26 …”

“…In keeping with previous literature, under-reporting of early pregnancy deaths, particularly those arising from complications of abortion or deaths prior to detecting pregnancy, and of maternal deaths arising from indirect causes that might have been reported as deaths due to medical causes (ignoring the pregnancy state) could have led to an underestimation of maternal deaths. 26 Maternal mortality in India's EAG states greatly exceeds the national average and is far from the target set out by the SDGs. Analysis of the results in the context of India's healthcare system suggests that targeted interventions to improve maternal outcomes in this population would include improved in-hospital care, improved access to healthcare services and guaranteed skilled personnel and basic emergency obstetrical care in every maternity centre.…”

Unmet Need for Family Planning among Urban and Rural Married Women in Yangon Region, Myanmar—a Cross-Sectional Study

“…It is estimated that if all the women in need of contraception have met needs, the induced abortions occurring in the developing world would reduce by 67%, and the number of maternal deaths as a consequence of unsafe abortion would decline from 22,000 to 4200 [25]. Despite abortion being legal in India, 89,447 abortion cases were reported in 2007–2011; 67% of these were unsafe abortions and 253 abortion-related deaths occurred [28].…”

A Stalled Revolution? Misoprostol and the Pharmaceuticalization of Reproductive Health in Francophone Africa

“…John, who worked on MA in Francophone Africa, revealed that in a previous position with an NGO in a southern African country, he had been warned directly by the MOH not to cross the line into legal advocacy for abortion. In India, where medication abortion is permitted in certified health facilities up to seven weeks and misoprostol and mifepristone are widely available at private pharmacies (Boler et al, 2009), an estimated 67% of abortions are classified as unsafe (Yokoe et al, 2019). In Ghana, where abortion is permitted for several indications, a 2016 study in the capital city of Accra showed that only half of pharmacies stocked misoprostol, with pharmacies in less affluent neighborhoods less likely to do so (Ganle et al, 2019).…”