Feasibility of Expanding the Medication Abortion Provider Base in India to Include Ayurvedic Physicians and Nurses

Article excerpt

CONTEXT: The availability of trained abortion providers is limited in India. Allowing ayurvedic physicians and nurses to perform medication abortions may improve women's access to the procedure, but it is unclear whether these clinicians can provide these services safely and effectively.

METHODS: Allopathic physicians, ayurvedic physicians and nurses (10 of each), none of whom had experience in abortion provision, were trained to perform medication abortions. In 2008-2010, these providers performed medication abortions in five clinics in Bihar and Jharkhand for 1,225 women with a pregnancy of up to eight weeks' gestation. A two-sided equivalence design was used to test whether providers' assessments of client eligibility and completeness of abortion matched those of an experienced physician "verifier,"and whether medication abortions performed by nurses and ayurvedic physicians were as safe and effective as those done by allopathic physicians.

RESULTS: Failure rates were low (5-6%), and those for nurses and ayurvedic physicians were statistically equivalent to those for allopathic physicians. Provider assessments of client eligibility and completeness of abortion differed from those of the verifier in only a small proportion of cases (3-4% for eligibility and 4-5% for completeness); these proportions, and rates of loss to follow-up, were statistically equivalent among provider types. No serious complications were observed, and services by all three groups of providers were acceptable to women.

CONCLUSION: Findings support amending existing laws to improve women's access to medication abortion by expanding the provider base to include ayurvedic physicians and nurses.

International Perspectives on Sexual and Reproductive Health, 2012, 38(3):133-142, doi:10.1363/3813312

Abortion has been legal in India since the Medical Termination of Pregnancy Act went into effect on April 1, 1972; the use of mifepristone and misoprostol for medication abortion has been legally permitted since 2002.(1), (2) Women have the right to obtain abortions in a range of situations: if the mother's life, or her physical or mental health, is at risk; if the pregnancy is the result of rape; if the pregnancy is likely to result in the birth of an infant with physical or mental abnormalities; or if the pregnancy is the result of contraceptive failure. Abortions may be performed up to 20 weeks' gestation, and a woman undergoing an abortion does not require the consent of the husband or guardian if she is aged 18 or older. However, the procedures must be done in registered facilities, and only by gynecologists, or by other allopathic physicians who have undergone special training and obtained certification in the provision of surgical abortion. (1) Over the years, the Government of India has made concerted efforts to increase access to safe abortion. For example, certification procedures have been rationalized, and rules and regulations amended, so that a certified provider now can perform a medication abortion in an unregistered facility, as long as he or she has access to a registered facility for backup. (1)

Despite this favorable legal scenario, access to safe abortion is limited in India; a large proportion of surgical abortions continue to take place outside of registered facilities, and a considerable proportion of both surgical and medication abortions are performed by uncertified providers. As a result, 8% of maternal deaths are attributable to unsafe abortion. (3) The obstacles to access are wide ranging. Many women are unaware that abortion is legally available, (4,5) or opt for an unsafe provider over a trained one because of concerns about confidentiality, cost and quality. (6) Health system-related obstacles are also evident. A leading barrier to safe abortion has been lack of access to appropriate facilities and the limited availability of trained providers; (7) nationally, only 12,510 facilities are registered to provide legal abortions, (8) and few primary health centers have abortion facilities. …