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As part of a Population Council programme of research on unwanted pregnancy and induced abortion in Rajasthan the Population Council and the Centre for Operations Research and Training conducted a situation analysis of abortion services in both the formal and informal sectors in six districts of Rajasthan. Non-random sampling procedures were used to select formal-sector abortion facilities and informal-sector abortion providers in purposively selected district headquarters and several medium-sized towns as well as in villages and smaller towns surrounding those urban localities. As we interviewed administrators and providers and conducted physical and equipment assessments at both certified and uncertified abortion facilities in the formal sector and interviewed a range of abortion providers in the informal sector the study offers important insights into the availability and organisation of abortion services in the sampled areas in Rajasthan. Despite a strong national commitment to improve the accessibility of abortion services in India the study shows that only one-third (35 percent) of the 105 formal-sector facilities offering abortion in our sample are in the public sector and just 28 percent are in rural areas. Among the lower-level public facilities identified in the catchment area only 2 1 percent of primary health centres and 65 percent of community health centres offer abortion services suggesting that poor rural women have few options when faced with unwanted pregnancy. Almost two-thirds (65 percent) of private-sector facilities and 58 percent of public-sector facilities sampled are not certified to provide abortions under the MTP Act. Although the majority of facilities are not certified to provide abortions 63 percent of the 119 formal-sector abortion providers interviewed have the requisite education and/or training to perform abortions indicating that services in the formal sector whether legal or not are likely to be safe. Nonetheless the study findings also indicate that the quality of services in the formal sector can be improved substantially. The majority of formal-sector abortion providers use outdated techniques to perform surgical abortions including dilatation and curettage. The easier and safer techniques of electric and manual vacuum aspiration are used far less frequently even for abortions at the earliest gestational ages. Pain management for surgical procedures can be similarly improved as our study identified a substantial proportion of providers using either general anaesthesia or no pain management for first-trimester abortions. Significant social barriers to care exist. Facilities routinely refuse to perform abortions in a number of circumstances including if a woman presents alone is married but nulliparous or is unmarried. Although not required by law consent of womens husbands and other family members is not uncommon and may impede womens ability to reach their reproductive goals. While formal-sector providers are well aware of the majority of circumstances under which abortion is legal in India confusion remains regarding the legality of abortion for unmarried women. The study also documented a vast array of informal providers who offer services for delayed menstruation or unwanted pregnancy. Informal providers appear particularly accessible to women because they are far more prevalent in rural areas than formal providers are generally well known in the community in which they practise maintain extended working hours and sometimes provide care at womens homes. The majority of informal providers offer tablets to provoke abortions but report low success rates with them. Few informal providers report using invasive methods for the treatment of delayed menstruation. Taken together these findings clearly underscore the need to improve access to affordable high-quality legal abortion services particularly in rural areas. Until this is done informal providers and uncertified facilities will remain the best option for poor and rural women despite the fact that abortion has been legal in India for over 30 years. (authors)

As part of a Population Programme of Research on unwanted pregnancy and induced abortion in Rajasthan the Population Council and the Centre for Operations Research and Training conducted a community-based study of unwanted pregnancy and induced abortion in six districts of Rajasthan. Multistage stratified sampling techniques were used to identify 3266 ever-married women aged 15-44 and 60 of their husbands in purposively selected district headquarters and several medium-sized towns as well as in villages and smaller towns surrounding those urban localities. Detailed pregnancy histories yielded data on levels of unwanted pregnancy and induced abortion in the sampled areas in Rajasthan. Women with abortions in the five years preceding the survey provided information about their knowledge of and opinions about abortion law risks and services. The study shows that rates of abortion are considerable with 13 percent of women reporting at least one induced abortion. The vast majority of women had abortions because they (59 percent) or their spouse (18 percent) wanted to limit their family size or space their childbearing (22 percent). Sex preferences appear to drive only a very small proportion of women (3 percent) to terminate their pregnancies. Womens husbands often participated in the decision to seek an abortion (55 percent) or were solely responsible for the decision (25 percent). For many women abortion is often a process that entails the consumption of home remedies as well as the use of services in the informal and formal sectors. Twenty percent of women with abortions reportedly used a home remedy or obtained services from an informal provider in an attempt to terminate their pregnancies. As these actions were not always successful the majority (89 percent) of women eventually sought services from the formal sector. Even when seeking services in the formal sector though some women had to visit more than one provider to terminate their pregnancies. Private-sector doctors emerged as important providers of abortion in both urban and rural areas used by 43 percent of all women seeking services in the formal sector. Access to services and quality treatment was particularly poor in rural areas. Only five percent of rural women with abortions obtained the service locally in their own village. One-quarter (24 percent) travelled over one hour to reach an abortion provider. Although provisions for free abortion services exist in the public sector both rural and urban women incurred at least some out-of-pocket costs when obtaining an abortion. In many cases (34 percent) these cost were well over 500 Indian Rupees. Post-abortion contraception counselling and adoption was low representing a significant lost opportunity. While most women obtaining abortions desired to limit or space their childbearing the majority (60 percent) of them did not receive any information or counselling regarding family planning particularly in rural areas where only 17 percent indicated that providers discussed family planning with them. Similarly while 60 percent of women adopted a method of family planning after their abortions use was sometimes short-lived limited to less than one month in 17 percent of cases. Levels of post-abortion morbidity were relatively modest in our study and surprisingly similar across our urban and rural samples. Nearly all women who experienced morbidity however indicated that the problems they encountered affected their daily life--leaving them bedridden for at least one day (83 percent) or unable to complete routine household chores (83 percent). Nearly half (45 percent) of women with post-abortion complications sought formal treatment for them and a fair number (13 percent) were hospitalised. Knowledge of the legality of abortion was low with only 16 percent of men and 17 percent of women aware of the legal right to pregnancy termination. Rural women were particularly unlikely to know that abortion is legal. When combined with poor access to services in rural areas this lack of information may contribute to continued reliance on informal providers and uncertified formal providers. These findings suggest that the legal right to abortion is not a reality for the majority of women in our sample in Rajasthan. Women in the study sample clearly have strong desires to meet their reproductive intentions. Existing methods of family planning and abortion services however are not meeting their needs. Public information campaign to educate women their spouses and other family members about the legal right to abortion and efforts to revise the MTP Act are imperative if access to abortion services is to improve. (authors)