Exploring the Transformative Potential of Medical Abortion for Women in India A value chain analysis From Manufacture to Social Change Study team : Priya Nanda, Alka Barua, Suchitra Dalvie**, Shuchita Mundle, Ashutosh Paturkar ** Presenting author

“ Pharmaceuticals are not only products of human culture but producers of it. As vehicles of ideology, facilitators of self care, and perceived sources of efficacy, they direct people’s thoughts and actions and influence their social life. The availability of medicines affects how practitioners and patients deal with sickness.” ( Geest et al, 1996, page 157)

Medical Abortion Pills in India In 2002 the Drug Controller approved the use of Mifepristone (200 mg) followed by Misoprostol (400 µgm) oral for upto 49 days gestation. MTP Act amended in 2003 to facilitate provision of MA Currently around 20 brands available in the market, price range from USD 2 to 6 for single Mife pill. Combipack approved for use upto 63 days Approx 10 million Mife pills sold in 2009 Despite this Access to & use of MA pills is limited

We asked…….. Does MA meet the abortion service needs of women? Can access for those needing safe abortion services be widened with the availability of de-medicalized MA? How much can access to MA be increased without compromising quality and safety?

Supply Chain Policy makers Manufacturers Stockist/ Retailers Providers Women Focus Market Profit Competition Distribution Focus Relevant, distinctive, consistent laws Focus Brands in demand Adequate stocks Distribution channels Focus Services in demand Meet client needs Profit (??) Competition (??) Focus Easily available Easy to use Safe Effective Affordable Confidential

Supply Chain: Expected Value Addition Policy makers Liberal policies & laws that support information, access & good quality services Manufacturers Ensure widespread easy availability of effective, safe, affordable commodity. Provide information on commodity Stockist/Retailers Knowledgeable, Support access, Ensure supplies, Provide information about commodity Providers Knowledgeable, Trained, Give information, choice, Provide safe services, Follow protocol Ensure confidentiality Women Find it Safe Easy-to-use Private Cost effective Non-surgical Non-invasive

Study Design & Methodology Qualitative with Mapping and In-depth interviews Site: Western state in India, Urban + Rural area Sample: – Stakeholders: 13 – Stockists: 8, Retailers: 28 – Service Providers: 39 (Formal & Informal) – Women Users: 120 (h/o Induced abortion <= 2 years)

Women Acknowledge the positive and potentially transformative attributes of MA pills Though the decision for the abortion was a joint one, most felt that the woman should choose the method All 120 MA users expressed a sense of relief Reported easy availability, affordability & privacy. Do NOT want to do it alone ! Source: IDIs with Providers & Women users of MA pills

Access a diversified provider base, both within & outside the purview of the law Reasons: Convenience, familiarity, affordability, confidentiality

Providers Followed different protocols for everything! Consent Confirmation of pregnancy Information on need for surgical intervention, FU Tablets: Regimen variable, 2 to >=4, Oral / vaginal ObGyn not supportive of MA demedicalization

“ On day 1 we give Mife 200mg 1 or 2 tablets orally. After 48 hours we give 4 tablets of Miso 2 orally and 2 PV or only 1 PV depending upon dilatation. On day 5 we confirm completion of the procedure. If not complete after 48 hours, sometimes we repeat 2 tablets of Mife 12 hourly. Also we titrate the dose of Miso. If she doesn’t abort with one tablet of Miso, we give 2 tablets and if she is overweight, we give 3 tablets of Miso stat.” ISM practitioner, 15 years rural practice

Limited knowledge about the MA pills & relevant laws, policies & guidelines

Retailers See it as just another product Most often men come to buy the pills Claim to ask for prescription every time but women confirm OTC sales Great need for values clarification Lack of information about drug s/e

Access Not yet in the public sector Pharmaceutical companies and social marketing organizations appear to be directing the expansion of this method. Sales are increasing by 40% every year. Is this necessarily good ? ( rights based approach and accountability of health systems ??) It is currently easier to access it outside the legal system than within. Although much cheaper than surgical, cost is still an issue for some.

Concept of ‘Misuse’ Use by unmarried women At higher gestational age ( 2 nd TM and Sex selection) Incorrect or incomplete regimen Lack of medical supervision and Lack of follow up and lack of post abortion contraception

Transformative potential along a value chain: Scenario Policy makers Liberalize law & access Provide information & access points Manufacturers Reduce cost Information Distribute widely Stockist/Retailers Stocks Access Knowledge Information Providers Information Knowledge Choice Safe services Follow-up Counselling Women Safe Easy-to-use Private Non-surgical Non-invasive Choice Cost Information

While none of the women interviewed spoke of empowerment or rights as an issue, it was clear that the existence of MA as a method moves them from a position of no choice to some choice and from some choice to more choice and therein is the beginning of the social transformation. There is a sense that this is a technology whose time has come and women are increasingly likely to demand as well as obtain access by their own means.

Thank You