1. Making Abortion Safe in Asia: Singularity of Focus Priya Nanda International Center for Research on Women (ICRW) APCRSH, Beijing, October 19 th, 2009

2. Abortion Scenario in Asia 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

3. 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. –.

4. Introduction of MA Pills in India Combination of oral Mifepristone (200 mg) followed by Misoprostol (800 µ gm) 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

5. 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

6. 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, X th grade, rural woman with 1 son

7. Women acknowledge positive and potentially transformative attributes of MA Users articulate a sense of relief on complete abortion 1/3 rd 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

8. 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.

9. 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

10. >50% providers not aware of stipulations under MTP Act >50% providers unaware of guidelines for MA 2/3 rd 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) Limited knowledge about relevant laws & guidelines

11. 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 Contrasting views about types of providers who can prescribe & where

12. 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

13. 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]

14. 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]

15. 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 Abortion within a Rights-based Framework

16. 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]

17. 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] 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”.