ABORTION COSTS AND FINANCINGA REVIEW

Ramamani Sundar

Abortion Assessment Project - India

First Published in September 2003

ByCentre for Enquiry into Health and Allied ThemesSurvey No. 2804 & 2805Aaram Society RoadVakola, Santacruz (East)Mumbai - 400 055Tel. : 91-22-26147727 / 26132027Fax : 22-26132039E-mail : cehat@vsnl.comWebsite : www.cehat.org

© CEHAT/HEALTHWATCH

Printed atChintanakshar GraficsMumbai 400 031

The views and opinions expressed in thispublication are those of the author alone anddo not necessarily reflect the views of thecollaborating organizations.

TABLE OF CONTENTS

PREFACE v

ABSTRACT vii

GLOSSARY OF TERMS AND ACRONYMS viii

I. INTRODUCTION 1

II. HOUSEHOLE EXPENDITURE ON ABORTION : FINDINS FROM SURVEYS 2

III. COST OF ABORTION AT DIFFERENT TYPES OF MTP CLINICS IN DELHI 7

A. FAMILY PLANNING ASSOCIATION OF INDIA 7B. PARIVAR SEVA SANSTHA (MARIE STOPES CLINICS) 8C. PRIVATE MTP PROVIDERS (GOVERNMENT APPROVAL) 9D. PRIVATE ILLEGAL PROVIDERS OF ABORTION 11

IV. COST EFFECTIVENESS OF DIFFERENT METHODS OF ABORTION 12

A. DILATION AND CURETTAGE (D & C) VS. MANUAL VACCUM ASPIRATION (MVA) 12B. MEDICAL ABORTION VS SURGICAL ABORTION 15

V ROLE OF THE STATE IN IMPROVING THE ACCESS TO MTP SERVICES 17

VI HEALTH INSURANCE SCHEMES AND ABORTION 21

VII CONCLUDING REMARKS 25

REFERENCES 26

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Abortions have been around forever. Butat different points of time in history it hasreceived attention for differing reasons, somein support of it, but often against it. Abortionis primarily a health concern of women butit is increasingly being governed by patriar-chal interests which more often than notcurb the freedom of women to seek abortionas a right.

In present times with the entire focusof women’s health being on her reproduction,infact preventing or terminating it, abortionpractice becomes a critical issue. Given theofficial perspective of understanding abortionwithin the context of contraception, it is im-portant to review abortion and abortion prac-tice in India.

The Abortion Assessment Project India(AAP-I) has evolved precisely with this con-cern and a wide range of studies are beingundertaken by a number of institutions andresearchers across the length and breadthof the country. The project has five compo-nents:I. Overview paper on policy related issues,

series of working papers based on exist-ing data / research and workshops to poolexisting knowledge and information inorder to feed into this project.

II. Multicentric facility survey in six statesfocusing on the numerous dimensionsof provision of abortion services in thepublic and private sectors

III. Eight qualitative studies on specific is-sues to compliment the multicentricstudies. These would attempt to under-stand the abortion and related issuesfrom the women’s perspective.

PREFACE

IV. Household studies to estimate incidenceof abortion in two states in India.

V. Dissemination of information and litera-ture widely and development of an advo-cacy strategy

This five pronged approach will, hope-fully, capture the complex situation as it isobtained on the ground and also give policymakers, administrators and medical profes-sionals’ valuable insights into abortion careand what are the areas for public policy in-terventions and advocacy.

The present publication is the Forth inthe AAP-I series of working papers.Ramamani Sundar has reviewed researchliterature and emprical data on abortion costsand financing and presented significant in-formation on public and private service pro-viders. Author suggested state interventionis more effectively needed in the form ofregulation, subsidies and social security.

We thank Sunanda Bhattacharjea for as-sisting in the language editing of this publi-cation and Mr. Ravindra Thipse, Ms. MurielCarvalho and Margaret Rodrigues for timelypublication of this entire series.

This working paper series has been sup-ported from project grants from TheRockefeller Foundation, USA and The FordFoundation, New Delhi . We acknowledge thissupport gratefully.

We look forward to comments and feed-back which may be sent to cehat@vsnl.comInformation on this project can be obtainedby writing to us or accessing it from thewebsite www.cehat.org

Ravi Duggal22nd September 2003 Coordinator, CEHAT

ABSTRACT

The growing literature on abortions inthe developing countries tend to focus on thehealth consequences of unsafe abortions andthe limited access to abortion services, butdoes not look at the real and often cripplingeconomic cost of abortion. A woman under-going an abortion has to incur expenditurein various forms, both direct and indirect.

So far no all India household survey onabortion related expenditure has been con-ducted. However there are micro level sur-veys, which had been carried out in a spe-cific state or a district, specially focussing onabortion. These surveys do throw some lighton the expenditure incurred by women onabortion, although the sample size of abor-tion seekers covered by some of these stud-ies is fairly small.

These studies show that women have toincur some expenditure to get MTP serviceseven from public clinics, which are expectedto provide free services. However, by and largethe government providers seem somewhatcheaper and are probably safer than the oth-ers, especially the illegal providers.

Unfortunately, none of these studieshave tried to look into the sources of financ-ing the abortion expenses by the women. Also,the surveys included only women who had un-dergone an abortion from the approved MTPcentres ; none of the surveys made an at-tempt to include the abortion seekers fromillegal providers. Another limitation of thesesurvey data on abortion cost is that it doesinclude the cost of follow up care and this costcan be very high in case there is a complica-tion after the MTP.

A visit to different types of MTP providersin Delhi reveals that there are a wide rangeof services available across the city. The typeof providers include government hospitals,family welfare centres, clinics run by NGOslike the Family Planning Association of In-dia and Marie Stopes, government approvedas well as not approved qualified private doc-tors and illegal providers like dais and quacks.These providers cater to different segmentsof the city’s population and the quality of ser-vices offered and the charges for abortionservices also vary accordingly.

The safety and the cost of abortion, to alarge extent would depend upon the methodof abortion used. The dilation and curettage(D&C), is still the most commonly usedmethod of abortion in India. The alternativemethod for early abortion, manual vacuumaspiration (MVA) is not widely available in thecountry even in the government run MTPclinics. As a result the average cost of abor-tions becomes very high.

Finally as far as abortion services areconcerned, the option of insurance schemesis almost non- existent in the country. In factin India health insurance is yet to pick up ina big way. Of the various schemes meant forthe employees of the organized sector theESIS, CGHS and the Railway Health Schemeprovide MTP services for the women coveredunder their schemes in the hospitals run bythem. Other insurance schemes as yet do notcover abortions .

A review of the available literature indi-cates that there is very limited data on thecost of abortion care in the country and hence

vii

the first step is to increase the research inthis critical area of financing for abortioncare. We need to know not only about the abor-tion charges at the various types of MTP cen-tres, but also the household dynamics likethe source of financing the abortion etc. It isevident that even in the government facili-ties, the abortion seekers had incurred sub-stantial expenditure. The state has to really

look into this. In the case of private certifiedapproved MTP centres, there do not seem tobe any control over the quality of services aswell as on the charges for the abortion ser-vices. We need much better regulation ofprivate medical practitioners as well as dis-semination of information to them so thatwomen seeking an abortion are not exploitedfinancially.

viii

GLOSSARY OF TERMS AND ACRONYMS

ANMs Auxiliary Nurse Midwife

CHCs Community Health Centres

Dai Untrained birth attendant

D&C Dilation and c urettage

FRUs First Referral Unit

GA General anaesthesia

IUD Intrauterine Device

MCH Mother & Child Health

MVA Manual Vacuum Aspiration

OPD Out Patient Department

OT Operation Theatre

PHCs, Primary Health Centres

PP Post partum

RH Rural Hospitals

ix

I. INTRODUCTION

There is a growing literature on thehealth consequences of unsafe abortions inthe developing world and the need to makesafe and easy abortion available to all womenwho need them. However, this growingliterature tends to focus on the health andpsychological costs of poor or limited accessto abortion. It does not look at the very realand often crippling economic costs ofobtaining abortion. The access to abortionservices not only includes the availability ofgood quality care in all geographical locations(especially at the primary level of care) andassured privacy and confidentiality, but alsomeans that the services should be availablefree or at an affordable cost. The cost of anabortion can be substantial for women whoturn to the private sector and even whenwomen seek an abortion from the MTPcentres run by the government, the servicesare not free and women do incur someexpenditure (CORT, 1996, CORT 1997a,IIHMR, 2000).

In addition, the public health facilitieshave a tendency to put pressure on womento accept sterilisation or a long actingcontraceptive like intrauterine device (IUD)after an abortion (Passano, 2002, Khan, M.E.et al 2001, Ganatra, B.R., et.al. 1996). Thelinking of MTP services with compulsoryadoption of contraception reduces women’swillingness to use the free services that areavailable (Ravindran, T.K.S. and R.Sen,1994). Although after the officialannouncement of a ‘ target free approach’ in

1996, the system of staff requiring to meetquotas for sterilisation acceptance issupposed to have been abolished, in practicenothing much has changed. This is not onlytrue of public providers, but is also the casewith some of the leading NGOs, who offer safeabortion services at a fairly reasonable cost.For instance, the data collected from the outpatient department (OPD) registers of theclinics of the Family Planning Association ofIndia at Delhi showed that of the sample of811 women who underwent MTP in theirclinics during the year 2001-02, 70 per centhad undergone tubectomy and another 27 percent had gone in for IUD. While contraceptivecounselling is essential to prevent thecommon phenomenon of repeat abortions,what is of concern is that too often thiscounselling is replaced by pressure to acceptterminal methods of birth control.

There is very little data on the economicfactors that may limit access to abortion.Several groups of women may not be able toafford the cost of an abortion. This includesnot only poor women, but also women whohave to obtain an abortion in secret andtherefore cannot get family money for thisand young unmarried women who similarlycannot turn to their families for help. Sincethere is lack of privacy and confidentialityin public health facilities, these women turnto private providers who exploit the situationand charge an exorbitant fee (ChakravarthyS, 1996, Passano, P .2002). A womanundergoing an abortion has to incurexpenditure in various forms, both direct andindirect. While the direct cost includes

ABORTION COSTS AND FINANCINGA REVIEW

1

expenditure incurred on travel to the clinic,hospital and room charges, doctors fee andcost of medicine, food and follow up care, incase the abortion results in complications,the indirect cost would also include the lossof wages.

In India, where there is no system ofhealth insurance and private expenditure onhealth is much greater than governmentexpenditure, there is therefore a need toknow much more about the costs of abortionand the economic barriers to abortion. Thepresent paper reviews existing empiricaldata and the research literature tounderstand some of these costs. Thisinformation is likely to point to areaswhere the state can intervene moreeffectively in the form of additionalregulation, targeting the provision ofabortion clinics, provide subsidies andsocial security in the form of insurance.l In Section II of this paper, the findings

of some of the household surveysconducted in various parts of India areput together to get an idea of theexpenditure incurred by women forseeking abortion services from differenttypes of providers across various states.

l Section III looks at the charges forabortion services in different types ofMTP clinics in Delhi and the socio-economic background of women who visitthese facilities.

l Section IV covers the cost effectivenessof different methods of abortion. Thediscussion ranges over the debate onD&C Vs MVA and Medical abortion VsSurgical abortion.

l Section V studies the role of the state inimproving access to MTP services. Itprovides an appraisal of the trend ingovernment funding for MTP servicesand government subsidies to institutionsproviding MTP facilities in the form ofsupply of equipment and free training ofdoctors, followed by an assessment of the

role of the government in improving theaccessibility of MTP services.

l Section VI deals with health insuranceschemes and abortion, the financialburden of abortion cost on the householdsand the availability of insuranceschemes are discussed.

l Section VII the last section, concludeswith suggestions on some policyrecommendations and a future empiricalresearch agenda on abortion cost andfinance.

II. HOUSEHOLD EXPENDITUREABORTION : FINDINGS FROMSERVEYSIn India, nationally representative

household surveys on health care utilisationand expenditures have been undertaken bythe National Sample Survey Organisations(NSSO), the International Institute ofPopulation Sciences (IIPS) and the NationalCouncil of Applied Economic Research(NCAER). The two rounds of National FamilyHealth Surveys conducted by the IIPS and theNSS 52nd round on Maternal and ChildHealth Care collected detailed informationon maternal and child health seekingbehaviour, but it did not gather any data onhousehold expenditure. Although the allIndia morbidity surveys conducted by theNSSO and the NCAER collected data onexpenditures incurred by the households onmorbidity, they do not have any data onabortion related expenses. However, thereare smaller surveys, which had been carriedout in a specific state or a district, speciallyfocussing on abortion services. This includesstudies undertaken by the Centre forOperations Research and Training (CORT)and Parivar Seva Sanstha (PSS). In additionto these studies, organisations like theCentre For Enquiry into Health AlliedThemes (CEHAT), Foundation for Researchin Community Health (FRCH) and the IndianInstitute of Health Management Research(IIHMR) have conducted surveys either on

2

health status of women in general or on thereproductive health of women. Though thesample size of abortion seekers covered bysome of these studies is fairly small, thestudies do throw some light on theexpenditure incurred by women on abortion.

The two studies conducted by the FRCHare probably the earliest attempts tounderstand household expenditure on healthcare in the country. The first FRCH studycovered 1629 households over three rounds(average of 543 households per round) in theJalgaon taluk of Maharashtra (Duggal Raviand Suchetha Amin, 1989). In addition tocollecting information on morbidity, thissurvey also collected data relating toutilisation and expenditure on maternityservices, for a period of 18 months (Jan 1986to June 1987). Only 7 cases of MTPs werereported during the period and all theabortions were performed in private hospitalsboth in the case of rural as well as urbanpopulation. The average cost of an abortionhad worked out to be Rs 300.43. Consideringthat the mean per capita income of thesample households was as low as Rs1865.80per annum, the abortion expenses must haveupset their budget, since these women hadto pay out such a large proportion of theirincome.

The second FRCH study was conductedin 770 households covering a population of5202 in the two districts of Sagar and Morenain Madhya Pradesh (George, Alex et. al,1994). The survey collected data onmaternity events viz., pregnancy, abortionand delivery during the period 1 Jan 1990 to31 January 1991, i.e. for 13 months. Only 8abortion cases were recorded and the averagecost per abortion was as high as Rs1258.13.The cost of abortion was higher in rural(Rs1497.83) than in urban (Rs539) areas,indicating the poor accessibility of freeabortion services in the rural areas.Furthermore, the two events reported fromthe urban areas had availed of free services(not reported under paid events) and hence

the cost was much lower. The study alsoreported that it was the household, whichbelonged to the lowest, and the lower middleeconomic status, which had spent more thana thousand rupees per abortion.

The Centre for Operations Research andTraining (CORT) had carried out situationanalysis of MTP services in the states ofGujarat, Maharashtra, Tamil Nadu andMadhya Pradesh. Besides examining theavailability of facilities, methods used forMTP, the status of health personnel,including their training needs etc., thesestudies also made an attempt to contactsome of the women who had availed of theMTP services from the sample clinics. TheCORT study in the state of Gujarat wascarried out during 1995-96 in 11 selecteddistricts out of 19 districts in the state witha focus on rural areas (CORT, 1995). Thestudy covered 54 PHCs, 27 CHCs and 54private doctors\clinics performing MTP. Inall 36 acceptors of MTP were interviewed andon an average, an acceptor had to spendRs229, of which two thirds was towardsdoctor’s fees. The remaining one-third wastowards hospital room charges, medicine,transport and miscellaneous expenses. Theaverage expenditure for private clinics wasgiven as Rs394 and for public clinics it waslower at Rs136.

The study on the situation analysis ofMTP services carried out by CORT in the 17districts of Maharashtra in 1995-96 covered60 PHCs, 38 Rural Hospitals (RH) and asample of private doctors\clinics (CORT,1996). As a part of the study 32 clients werecontacted. The mean monthly family incomeof the acceptors was Rs1884 and on anaverage they had spent Rs376 for MTPservices. While this was as high as Rs 447in private clinics, in government clinics itwas lower at Rs 361.

In the CORT study of situation analysisof MTP services in the state of Uttar Pradesh,the sample survey covered health facilities

3

registered for conducting MTP, spread over25 districts including private rural doctorsand private clinics in the semi-urban areas(CORT, 1997a). The study team contacted 126acceptors of MTP services - 38 from blockPHCs, 38 from CHCs, 24 from othergovernment facilities and 26 from privatedoctors/clinics. The average monthly familyincome was Rs1431 for those who came tothe public sector clinics, but it was higher atRs 2360 for those who went to private clinics.The women who underwent MTP in blocklevel PHCs spent on an average Rs 450, inCHCs it went up to Rs 484 and in othergovernment hospitals it was as high as Rs751. The acceptors of MTP services paid onan average Rs 649 in the private clinics. Inother words, while those who sought abortionservices from the public health facilitiesspent more than one third (37.3 per cent) oftheir monthly income, the acceptors whowent to private clinics spent marginally morethan one fourth (27.5 per cent) of theirmonthly family income. The acceptors ofMTP services mentioned that they had paiddoctors fees in all categories of hospitals,although it was supposed to be free in publicfacilities. This roughly accounted for 40-45per cent of total expenses in different categoryof clinics except in other government clinicswhere it was 52 per cent. In both governmentand private clinics hospital room charges alsocontributed substantially to the totalexpenditure. Expenditure on medicines wasmore or less the same in all categories ofclinics.

The study on the situation analysis ofMTP services in the state of Tamil Nadu wascarried out in 8 districts during 1996-97(CORT, 1997b). In all 38 block PHCs and 19sub-district hospitals were included in thesample. Since the private hospitals weretouchy about the subject the study team couldinclude only 6 of them. Similarly, due todifficulties in tracing the acceptors of MTPservices, only 14 women who underwentabortion in public facilities were interviewed.

On an average they had incurred anexpenditure of Rs 450 for undergoingabortion.

All the four CORT studies showed thatthe costs of abortion varied considerablyacross the states and by type of provider,i.e. whether the services were receivedfrom the public or private clinics. Thestudies revealed that the women had tospend between Rs136 to Rs 534 forreceiving the services from thegovernment clinics. In case of privateclinics, the cost ranged between Rs 394 toRs 649. On further questioning theproviders revealed that the expenses forMTP were directly linked with the gestationperiod at the time of MTP. For instance, itranged from Rs 331 in case of pregnancywithin 12 weeks, Rs 574 when pregnancywas 12-20 weeks and Rs 935 if thepregnancy was more than 20 weeks (CORT,1998).

The study conducted by CEHAT inMumbai on women’s health care focussedmainly on the pattern of morbidity, utilisationof health care services and the expenditureincurred on treatment (CEHAT, 2001). In thisstudy, from a sample of 466 currently marriedwomen information relating to maternityevents and use of contraceptives wasrecorded for the reference period of one year(May 1995 to April 1996). Only 3 cases ofabortion were reported and all these MTPswere performed at the private clinics. Theaverage expenditure on abortion worked outto be Rs 989.

The IIHMR carried out a study on thefinancing of RCH care in Rajasthan in 1999covering both the government financing ofRCH program in the state as well as thehousehold expenditure on maternal and childhealth care (IIHMR, 2000). A survey of 1100households (726 rural and 374 urban) wasconducted in the Udaipur district ofRajasthan. In these sample households allmarried women of reproductive age, except

4

those who had been sterilised, were askedwhether they had used any abortion servicesin the past two years Out of 864 women, only40 women had reported that they had had anabortion. Among those who respondedaffirmatively, 50 per cent chose governmentproviders and another 50 per cent had optedfor a private facility. The study found that 90per cent of all women who had an abortionincurred expenditure of some kind. Theaverage expenditure for all users (includingthose who did not pay anything) worked outto be Rs 925 and the average expenditure forthe users of private and public facilities wereRs 977 and 873 respectively. Medicinesabsorbed the major proportion of expenditure(51 per cent), especially among women usinggovernment services, implying that users ofpublic services also had to purchasemedicines from outside. Users of privateservices had comparatively paid more fortravel and lodging. Interestingly even in thecase of users of government services theconsultation charges accounted for 23 percent of the expenses.

The Parivar Seva Sanstha had conducteda survey of abortion seekers in Calcutta,Lucknow and Delhi in 1999 with the help ofGrasp consultants and with financial andtechnical support from the PopulationCouncil (PSS, 1999-2000). Three hundredwomen who had undergone an abortionduring the past six months from the date ofthe survey (November 1999) wereinterviewed. The sample was split equallyacross three cities and both rural and urbanareas were covered equally. The urbansample included population living in slumsand resettlement colonies as well as all otherpopulation. The rural population includedwomen who usually visit untrained birthattendant (dais) who may not have receivedany training in conducting abortions. Thus,the sample of abortion seekers was selectedfrom different localities, accessing differenttypes of facilities. The survey showed thatthough abortion seekers considered legal

centres to be more expensive than the illegalservice providers, the actual cost of abortionfrom the latter (mean cost of abortion is Rs802) turned out to be higher than in legalcentres (where the mean cost is Rs725),particularly in Lucknow and Calcutta. InDelhi, women who had sought abortionservices from legal providers had on anaverage spent Rs 1195, whereas those whowent to ‘illegal but good’ (qualified doctors butwithout the government approval as a MTPclinic) had paid only Rs 930. However, womenwho sought the services of ‘illegal and bad’providers (quacks, dais etc) had paid on anaverage Rs 1000.

This only goes to prove that seekingabortion services from quacks and daisneed not work out to be cheaper than theservice provided by qualified doctors

However, another recent study by theParivar Seva Sanstha showed that on anaverage the acceptors of MTP services atgovernment facilities incurred moreexpenditure as compared to women whosought abortion services from private doctors,dais and ANMs (who conducted abortionsprivately) (PSS, 2002). Although the rapidappraisal of abortion clients undertaken inthe districts of Orissa had a sample of only23 abortion seekers, the study wasqualitative in nature and case studies wereconducted to understand the dynamics ofunintended pregnancies. The abortionseekers who went to government facilitieshad incurred an average expenditure of Rs553 as compared to Rs 400 for private, Rs 300for dais and Rs 400 for ANMs. In addition tothis, the abortion seekers had spent Rs 455towards the cost of drugs. It is interesting tonote that the average cost of treating postabortion complication has worked out to bemarginally lower for those who went togovernment facilities (mean cost Rs 217) ascompared to those who went to private (meancost Rs 250).

It is evident from all the studies thatwomen have to incur some expenditure to

5

get MTP services even from public clinics,which are expected to provide free services.These studies show that in the public healthfacilities the abortion seekers not onlypurchase the medicines from outside, butalso seem to pay ‘fees’ in some form or theother. However, based on the findings of mostof the studies one could conclude that by andlarge the government providers seemsomewhat cheaper (although the differencesin expenses were marginal in some cases)and probably safer than the others, especiallythe illegal providers. Only a small proportion

of abortion seekers seem to know thatabortion is legal and a large proportion of themare not aware that a service provider needsa special license authorising him/her toconduct an abortion (PSS, 2000-01).

These household surveys also point outthe fact that the expenditure incurred by theabortion seekers varies a lot since there area wide range of service providers. Even inthe case of government approved MTP clinicsthere are wide variations and there is nogovernment control either on the quality ofservices or on the charges to be levied. This

Table 1. Cost of Abortion: Findings from Household SurveysSl. Study Study Area Reference Period Sample Size Av. HouseholdNo. of Abortion Expenditure Per

Seekers Abortion (Rs)1 FRCH,1989 Jalgaon Taluk, Jan 1986- June 1987 Private - 7 Private - 300.43

Maharashtra2 FRCH,1994 Sagar & Morena Jan 1990 -91 - 8 Rural - 1497.83

Districts, MP Urban - 539Total - 1259.13

3 CORT,1995 Gujarat 1995-96 -36 Private - 393.50(Mainly Rural) Govt. - 135.80

Total - 228.904 CORT, 1996 Maharashtra 1995-96 Private - 4 Private - 446.80

(Mainly Rural) Govt. - 28 Govt. - 361.30Total - 32 Total - 375.50

5 CORT, 1997a Uttar Pradesh 1996-97 Private - 26 Private -649.20(Rural) Govt. - 100 Govt. - 533.90

Total - 1266 CORT,1997b Tamil Nadu 1996-97 -14 Govt. - 450

(Rural)

7 CEHAT, 2001 Mumbai 1995-96 Private - 3 Private - 989

8 IIHMR,2000 Udaipur 1999 Private - 20 Private - 977Dist. Rajasthan Govt. - 20 Govt. - 873

Total - 40 Total - 9259 PSS, 1999-2000 Delhi 1999 - 300 Legal Providers - 725

Calcutta Illegal but good - 846.67Lucknow Illegal and bad - 802

10 PSS, 2002 Orissa 2002 - 23 Private -4003 Districts Dais - 300

ANMs - 400Govt. - 553

6

is confirmed by the visit to a number of MTPproviders in Delhi, as the next section willindicate.

As pointed out earlier, in all the studiesmentioned above, the sample size of theabortion seekers is very small and hence onecannot draw much inference based on sucha small sample. It may be difficult to get holdof a large number of abortion seekers andinterview them in a survey of this sort. TheCORT studies also faced a lot of field problemsin getting MTP acceptors on the day the teamvisited the sample clinics. To overcomethese problems the names of acceptors whohad availed the services within three weekspreceding the visit, were taken from theregisters. However, some of the acceptorsrefused to be interviewed.

Since the various surveys arecomparable neither in terms of sample size,nor in terms of their geographical coverage,one cannot draw any conclusion about thetrend over the years in the householdexpenditure on abortion.

Unfortunately, none of these studieshave tried to look into the women’s sourcesof financing abortion expenses. This isespecially important for poor women, womenwho seek the abortion services without theconsent of their husbands, women who arenot economically independent and forunmarried girls who get the MTP done inutmost secrecy. Another limitation of thesurvey data on abortion cost is that it doesinclude the cost of follow up care and thiscost is often very high where complicationsfollow an MTP.

III.COST OF ABORTION ATDIFFERENT TYPES OF MTPCLINICS IN DELHI

A visit to different types of MTP providersin Delhi revealed that there is a wide rangeof services available across the city. The typeof providers include government hospitals,

family welfare centres, clinics run by NGOslike the Family Planning Association of Indiaand Marie Stopes, government approved aswell as non-approved qualified private doctorsand illegal providers like dais and quacks.These providers cater to different segmentsof the city’s population and the quality ofservices offered and the charges for abortionservices also vary accordingly.A. FAMILY PLANNING ASSOCIATION OF

INDIA

The Delhi branch of the Family PlanningAssociation of India (FPAI) was inauguratedin 1963 and the FPAI currently has clinicsat two places in Delhi, one at RK Puram andanother at Pitampura and is providing areaspecific health and family welfare services.These two clinics, which are calledReproductive Health & Family PlanningClinic (RHFPC), provide services likeimmunisation of children, antenatal check-ups and family planning services includingMTP. Though these clinics cater to poor andlow-income households of Delhi, currently (asof 2002) women who seek abortion serviceshave to pay Rs 405. This includes Rs10 forthe OPD card, Rs 45 for the Syringe andLaboratory charges and Rs 350 as fee for MTPservices. In these clinics MTP is performedonly up to 10 weeks of pregnancy or in thefirst trimester, since they do not want to takeany risks and the Manual Vacuum Aspiration(MVA) method is used in these clinics. Whilethe charges are uniform for all the patients,if a really poor patient makes a request, a 50per cent concession is offered on the charges.Most of the women who undergo abortion aregiven painkillers and other medicines likeantibiotics free of cost, since they get freesupplies of these medicines from the DelhiGovernment. The acceptors of abortion haveto spend only 3 or 4 hours at the clinic.

Though there is no coercion to subjectthe women to either undergo sterilisation orgo in for an IUD insertion along with theabortion, they are counselled to accept a

7

method of family planning. Even though thereis growing pressure on the government todispense with the scheme of incentives anddisincentives, cash incentives are offered inthese clinics for accepting sterilisation, inkeeping with the policy of the Delhigovernment. If a woman agrees to adopt theterminal method along with the abortion, notonly is the abortion service free, but she isalso given a cash incentive of Rs 250 forundergoing a tubectomy or Rs 160 to herhusband for accepting vasectomy.

To understand the socio-economicbackground of the women who seek abortionservices in the FPAI clinics, a random sampleof 197 women was drawn from the OPDregisters out of the 811 women whounderwent MTP in 2001-02. The average ageof the women and their husbands was 28 and32 respectively. Nearly half of the women and25 per cent of their spouses were illiterate.While only 8.6 per cent of women weregraduates, among the husbands thepercentage of graduates was higher at 17.8.The average monthly household incomeworked out to be Rs 3614 and as many as 39per cent of them had a household income ofless than Rs2000 per month. Another 25 percent belonged to the Rs 2001 to 3000 monthlyincome categories (Table 2). Thus, most ofthe abortion seekers at this FPAI Clinicbelonged to poor or low- income households.The cost of an abortion for these women worksout to be 11 per cent of their monthlyhousehold income and this excludes otherdirect expenses like transport charges andindirect costs like loss of wages.

B. PARIVAR SEVA SANSTHA (MARIESTOPESCLINICS)The first Marie Stopes Clinics was

opened in Delhi in 1979 with the objective ofproviding access to safe abortion, subsequentto legalisation of abortions in India in 1972.Today there are 34 clinics spread over anumber of states and by the end of 2002-03,the number of clinics is likely to go up to 40.

Though originally started only as a providerof abortion services, today the servicesavailable at the Marie Stopes/ParivarSanstha Clinics include family planningcounselling, supply of contraceptives,medical termination of pregnancies,gynaecological consultations, insertion ofIUDs, male and female sterilisation,treatment for RTI/STI, diagnosis andtreatment of infertility, mother and childimmunisation (PSS 2000-2001).

The charges for MTP services vary fromclinic to clinic, depending on the location ofthe clinic. Each clinic has a different pricestructure depending on the image of theclinic i.e. whether it caters to low or middleincome households. Though there are nodifferences in the basic health care facilitiesoffered by different Marie Stopes clinics,there might be ‘Cosmetic’ differences, e.g.better furniture etc. According to the PSS,the rates are fixed keeping in mind thepaying capacity of women who seek theservices and the rental value of the buildingin which the clinic is located etc. We are toldthat, as a policy they ensure that fee for anabortion does not exceed one week’s wages.It is not very clear as to how this is ensured,since the rates are already fixed and withinthe clinic the charges do not vary fromindividual to individual. However, if a womanis really poor a clinic may subsidise herexpenses, but each clinic has a limitednumber of cases (quota), which they cansubsidise in a year. The charges for anabortion in Marie Stopes clinics vary fromRs 250 to 600 if the abortion is performedduring the first trimester and the methodused is Menstrual Regulation Syringe orMVA. If the MTP is performed within 12 to 16weeks of pregnancy, the charges vary fromRs 450 to 1500. Beyond 16 weeks, startingwith Rs1200, the charges may go up toRs3000. If the abortion is done in the secondtrimester, women may be asked toeither stay for one more day or asked to cometwice.

8

Table 2. Socio-Economic Profile ofAbortion Seekers at FPAI* &Marie Stopes Clinics in 2001-02

FPAI Marie StopesNo. of MTPs 811 74307Income **<1001 0.51 6.30 %1001-1500 5.58 0.40 %1501-2000 32.49 24.30 %2001-3000 25.38 22.04 %3001-above 36.04 46.96 %No. of LivingChildren **0 3.05 17.77 %1 12.18 23.97 %2 45.18 27.89 %3 24.37 18.77%4+ 15.23 11.59%Post AbortionContraceptionCondom - 25 %Oral Pills 0.50 % 15 %DMPA - 3 %IUCD 26.80 % 10 %Sterilisation 70 % 18 %None 2.70 % 29 %

All 100 100

Note (*) : Data refers only to the Clinics in Delhi.

(** ) : In the case of FPAI the percentagedistribution is based on the sample of 197 MTPSeekers

The abortion seekers at the Marie Stopesclinics are also counselled into accepting anappropriate method of family planning.However, unlike the FPAI clinics in Delhi,in the Marie Stopes clinics, even if a womanaccepts a post abortion sterilisation, she ischarged for the MTP, may be at a subsidisedrate. The incentive for accepting sterilisation

varies from state to state depending on thestate government’s policy. For instance inthe states like West Bengal, UP and Delhithere is incentive money, where as inRajasthan it is not there. It is worth notingthat of the 74,307 abortions conducted at thevarious Marie Stopes clinics in the countryduring the year 2001-02, only 18% hadundergone sterilisation. Another 10% had gotthe IUD inserted after the abortion and asmany as 29% of the women did not opt forany method of family planning.

The profile of the abortion seekers at theMarie Stopes Clinic revealed that nearly 19%of them already had 3 or more living childrenwhen they came for the abortion and another28% had two living children (Table 2). Thoughmost of the MTP clients of Marie Stopesclinics also belonged to poor or low incomehouseholds, they seemed to be better of thanthe clients of FPAI clinics at Delhi. As manyas 47 % of the abortion seekers at the MarieStopes clinics had a monthly householdincome of more than Rs3000. Another 22 percent belonged to the Rs 2001 to 3000 monthlyincome categories. However, more than 30%had a monthly income of Rs.2000 or less. Ofthe total number of MTP clients 87.5 per centwere Hindus and another 10 per cent wereMuslims.C. PRIVATE MTP PROVIDERS

(GOVERNMENT APPROVAL)According to the data available with the

Department of Family Welfare, Ministry ofHealth and Family Welfare, in 2001 the cityof Delhi had nearly 400 government approvedMTP centres. The private nursing homes/clinics have to get the certificate from thegovernment to run an approved MTP Centreand once in three years it has to be renewed.There is a wide range of service providersand the charges vary according to the qualityof services, location of the centre and thepatients to whom they cater.

Under this category of Governmentapproved MTP providers, gynaecologists from

9

four nursing homes were contacted- two fromEast Delhi, one from South and one from WestDelhi. A visit to a full-fledged nursing homein East Delhi which caters to the middle andupper middle class population, revealed thatMTP services are offered to women only upto a maximum of 10 to 12 weeks of pregnancy.The gynaecologist mentioned that she wouldnot like to take the risk of performing anabortion beyond the first trimester. Thenursing home charges Rs 3000 for anabortion and this includes charges for theoperation theatre (OT) and fee for ananaesthetist (since in this nursing homeMTP is done under general anaesthesia). Thenursing home does not seem to be gettingunmarried girls as clients for MTP services.

On the road opposite this nursing home,there is another government approved MTPcentre run by a lady doctor. This centre seemsto be handling mainly abortion cases (17 to18 cases a month), though she claims toprovide other services as well. The doctorwho is running the centre has a MBBS degreeand training to conduct MTP. She seems tobe terminating only pregnancies up to 10 to12 weeks, and her charges vary from Rs 400to 600. Interestingly, she had no hesitationin revealing the fact that her charges aremuch higher for unmarried girls and thecharges may go up as high as Rs1500. It hasbeen found in other studies also thatgenerally the costs were higher forunmarried girls when the procedure had tobe conducted in utmost secrecy (Passono, P.2002). Unfortunately it was not possible toget a profile of these girls, since the doctorwas quite secretive and was not willing toreveal any details.

A gynaecologist in a nursing home inNorthwest Delhi, which is registered underthe Nursing Home Act of the DelhiGovernment catering to middle classhouseholds of the locality, was contacted.Here again the gynaecologist seems to beproviding MTP services only up to 10 to 12weeks of pregnancy. The charges for a MTP

are around Rs1200. This nursing home toodoes not seem to attract unmarried girlswanting to abort unwanted pregnancies.

While opting for an abortion the educatedupper middle class women of Delhi seem veryfastidious about the nursing home. Agynaecologist in a small nursing home (runby her husband and herself) in South Delhimentioned that even though the nursinghome is located in an upper middle classlocality, only women from the lower middleclass background attend the clinic, since hernursing home is not posh enough. Thoughthe nursing home not being posh enough wasmentioned by the gynaecologist, as a reasonfor the upper middle class women not visitingher nursing home, there could well be otherreasons. The women in the neighbourhoodmay not prefer to be patients of this nursinghome, as they may be keen to undergoabortion in secrecy. The charges for MTPservices in this nursing home vary from Rs600 -1000 with local anaesthesia and Rs1600to 2000 with General anaesthesia. Thecharges do not increase in the case ofunmarried girls. On an average thegynaecologist does 15 abortions in a monthand again she would not entertain pregnantwomen coming for an abortion after the firsttrimester. Interestingly, she also offersmedical abortion (see the next section for adetailed discussion on medical abortion) towomen who come for the termination ofpregnancy at an early stage (within 6 weeks).Though the medicine cost has come downdrastically, she continues to charge a highfee (Rs 2000). In her opinion other doctors inSouth Delhi are charging much higher rates-Rs 3000 - 5000 for a medical abortion.

Two interesting observations emergefrom the visits to the government approvedprivate clinics in Delhi.l Firstly, gynaecologists generally do not

want to take the risk of providing MTPservices to pregnant women beyond thefirst trimester. One probable reason forthis could be that these nursing homes

10

might not have the necessary back upservices, in case there is somecomplication during the MTP procedure.

l Secondly, as far as unmarried girls areconcerned, even if they do approach anapproved clinic, they seem to avoid full-fledged nursing homes (since thesenursing homes are generally crowded)and choose the secluded ones. The doctorin the East Delhi clinic is attracting alot of unmarried girls, since her clinicis on the first floor with the advantage ofa lot of privacy. Hence, she seems to betaking advantage of her location andcharging a high price. This is similar tothe findings of other studies. Forinstance, the CEHAT study of RuralMaharashtra also found that forabortions outside marriage, most womengave secrecy the greatest priority andopted for a discreet and distance locationinvolving a short waiting period (Gupte,Manisha et al 1997).

D. PRIVATE ILLEGAL PROVIDERS OFABORTION

The predominance of unauthorisedproviders like the dais, female paramedicsand doctors practising in other systems ofmedicine seem very common in many partsof the country (Chhabra, R.and S.C. Nuna,n.d., and Maitra, N, 1997). However what issurprising is that even in a city like Delhiwhere nearly 400 government approvedclinics are available, and a number of NGOshave outreach MCH activities specially in theslums and resettlement colonies, womenstill opt for the illegal providers. What are thereasons for this? How important is the costfactor? A visit to the Tigri camp and theresettlement colonies (near Khampur,Sangam Vihar) and discussions with thefemale field workers of an NGO working withadolescent girls and women in thereproductive age spans, provided someanswers to these questions. The traditionaldais who try various methods of abortion

(herbal etc) are not particularly inexpensive.They may charge anything between Rs 800 -1000. In the case of terminating theunwanted pregnancy of an unmarried girl,the charges could be even higher. In spite ofthis, women prefer to approach the dais orthe unqualified doctors because of ignoranceof the availability of approved clinics, as hasbeen pointed out by the PSS study (PSS, 2000-01). If a woman has to go to any of the clinicsrun by the NGOs or the government facilities,a whole day would be needed; distance andtime constraints are a major problem. Thisis especially difficult for women who seek theabortion services without the knowledge oftheir husbands or their in-laws and forwomen having small children. They are morefamiliar with the dai next door and alsoprobably have more confidence in her, sincethe dais also take care of them through childbirth. It has been found by a recent study thatnearly two-thirds of women living in theslums and resettlement colonies of Delhideliver at home with the help of untraineddais (Sundar, R. et al 2002). This familiaritywith the local dais and quacks gives theacceptors of abortion an additionaladvantage. It offers informal arrangementsfor paying the abortion charges like payingin instalments, loan against some surety,deferred payment etc.

IV. COST EFFECTIVENESS OFDIFFERENT METHODS OFABORTION

A. DILATION AND CURETTAGE (D & C) VS.MANUAL VACCUM ASPIRATION (MVA)The safety and the cost of abortion would

depend to a large extent on the method ofabortion used. Dilation and curettage (D&C)is still the most commonly used method ofabortion in India. D&Cs are usually doneunder general anaesthesia as an in-patientprocedure. The alternative method for earlyabortion, manual vacuum aspiration (MVA)is not widely available in the country even

11

in the government run MTP clinics. Theoperational strategies spelt out in theNational Population Policy, 2000 includesexpansion of access to safe abortion servicesthrough the introduction of simple and safeabortion techniques such as the ManualAspiration Technique. Till recently ingovernment hospitals D&C and ElectricalSuction methods were being used. Forinstance the CORT study found that for first

trimester abortions, the use of manualvacuum aspiration is low and the use of D&Cwas much higher at 72 per cent in CHCs,and 65 per cent in PHCs. (CORT, 1995).

The MVA has been pilot tested in threemajor government hospitals in Delhi and inview of its efficiency, the Medical Officers arebeing trained in this method, especially foruse in rural areas for MTP. The Government

12

Table 3 : Cost of Abortion at Different Types of Providers in DelhiSl. Type of Provider Type of Clients Services Offered ChargesNo.1 FPAI Clinics Poor & Low Income Only up to 10 • Rs 405

Households Weeks Pregnancy (Rs10 for an OPD card,Rs 45 for Syringe & LabCharges & Rs 350 as Fees).

2. PSS (Marie Poor, Low and Up to 20 weeks Up to 12 weeks-Stopes Clinics) Middle Income Pregnancy • Rs 250 to Rs 600.

Households 12 to 16 weeks-• Rs 450 to Rs 1500.Over 16 weeks-• Rs1200 to Rs 3000.

3 Full fledged Middle and upper Maximum up to • Rs 3000 under generalPrivate Nursing middle income 12 weeks anaesthesia (GA).Home in East households PregnancyDelhi

4 Approved MTP Lower middle & Up to 10 to Married women- Clinic, East Delhi middle income 12 weeks • Rs 400 to Rs 600.

households Unmarried girls-• Rs 1200. Medical Abortion• Rs 2500.

5 Private Nursing Middle income 10 to 12 weeks • Rs 1200.Home in North Households PregnancyWest Delhi

6 Private Nursing Lower Middle Up to 12 weeks Under local anaesthesia-Home in South Income Households Pregnancy • Rs 600 to Rs 1000. UnderDelhi GA- • Rs1600 to Rs 2000

Medical Abortion- • Rs 2000

7 Untrained Dais at Poor and Low Up to 12 weeks • Rs 800 to Rs 1000.Tigri Camp & Income Households PregnancyResettlementColony

has developed the ‘Guidelines for MedicalOfficers for Medical Termination ofPregnancies up to eight weeks using ManualVacuum Aspiration Technique’ to help theMedical Officers to provide safe abortionservices using simple and safe techniques(Government of India, 2001-02). The

Federation of Obstetrics and GynaecologicalSocieties of India (FOGSI) has issued astatement in support of the MVA method.MVA is considered to be quicker, safer andcan be performed as an out patient procedureand often there is no need for generalanaesthesia, hence there is less risk for

Table 4. Cost of MVA Vs D&C

Title of Study Study Details / Country Key Findings ReferenceInterventions considered

The cost oftreatingincompleteabortion inKenya : a costcomparison oftwo treatmentregimes

Linkages withtreatment forincompleteabortionsimprovefamilyplanningservices inKenya

Hospitalsreduce costsby improvingpost-abortioncare

Manual vacuumaspiration Vs sharpcurettage, in twohospitals, Eldoretand Machakos

Analysing data fromsix hospitals, thestudy aimed tocompare the cost,effectiveness andquality ofalternativeapproaches tointegratingemergencytreatment ofabortioncomplications withfamily planning

To cost post-abortioncare in sixcountries in Africaand Latin America.Cost data for bothMVA and D&C werecollected

Kenya

Kenya

AfricaLatinAmerica

MVA reduced equipmentcosts by 3 per cent ,reduced total stay inhospital by 41-76 percent and reducedpatient costs by 50 and66 per cent in the twohospitals

35 per cent ofgynaecology wardadmissions resultedfrom incompleteabortion. Theintroduction of MVArequired no anaesthetic,& smaller operationtheatres. This reducedwaiting times, and inMombasa the averagelength of stay fell from60 to 21 hours

Cost per patient for D&C= $ 78.81, cost perpatient for MVA = $ 8.50.89 per cent lowermedian costs for MVApatients. Average lengthof stay was reduced from36 to 15 hours The bulkof costs for bothinterventions aresalaries, and costs

Bradley J.Unpublished(Poplinesearchfinding),1990

Solo J,Billings D.Taken fromPopulationCouncilwebsite. n.d.

King TDN,BensonJ, Stein K.1998

13

Title of Study Study Details / Country Key Findings ReferenceInterventions considered

associated withinpatient overnightstay.

Patients treated forincomplete abortionwith MVA spent 77 percent less time in thehospital andconsumed 41 per centfewer resources thansimilarly diagnosedpatients treated withSC.

The total time(preoperative,operative, postoperative) was 271min. for MVA, 290min. for outpatientcurettage withhospitalisation. Thetotal mean cost perpatient (manpower,supplies, andadministration) wasUS $16.30 for MVA,$16.70 for outpatientcurettage and $ 84.11for curettage withhospitalisation. Givenan average of 20incomplete abortioncases per day, theInstitute would saveabout $50,000 a yearby treatinguncomplicatedabortion cases on anoutpatient basis.

Use of MVA inreducing cost andduration ofhospital-isationdue to incompleteabortion in anurban area ofnorth-easternBrazil

Treatment ofincompleteabortion ; manualvacuum aspirationversus curettage inthe MaternalPerinatal Institutein Lima, Peru

Comparison of MVAand sharp curettageinterventions forpost- abor tion care.

Comparison of MVAand sharp curettageinterventions forpost- abortion care

Brazil

Peru

Fonseca W,Misago C,Fernandes L,Correia L,Silveira D.Revista DeSaude Publica1997;31(5);472-478

Guzman A,Ferrando; D,Tuesta L.Unpublished -Taken fromPoplinedatabase1995.

Source : Jowett, M, ‘Safe Motherhood; Interventions in Low-Income Countries: An Economic Justificationand Evidence of Cost Effectiveness’ Health Policy 53 (2000) pp.201-228

14

women (Passano, 2002). Since using the MVAmethod does not require sophisticated backup equipment, it has been recommendedthat in early abortions MVA should bepreferred over D&C to increase accessibilityand for ensuring safety. While in the publichealth facilities MVM is being used only tilleight weeks of pregnancy, in the privatesector this method is used up to the firsttrimester. Currently all the gynaecologistsat the medical college hospitals are beingtrained in MVA and they would in turn trainthe doctors at the lower level.

A number of studies have shown thatusing MVA with local anaesthesia reducespatients’ health risks, lowers hospital costsand ensures speedy recovery. The use ofmanual vacuum aspiration rather than D&Ccan reduce the costs to both the providersand the patients and the evidence regardingthe cost effectiveness of MVA is availableespecially for the treatment of complicationsarising from abortion. The studies conductedin countries like Kenya, Africa, Brazil andPeru show that cost per patient works out tobe lower for MVA as compared to D&C forabortion procedure and for treatingcomplications arising from abortion, inparticular incomplete abortion (Jowett, M.2000). The findings of these studies showthat as compared to D&C, in the case of MVA,the cost per patient gets reduced due tovarious reasons like a fall in the averagelength of stay in the hospital, requiring onlysmall operation theatres, not requiringanaesthesia etc. The studies conducted inAfrica and Latin America showed that thebulk of hospital costs for both D&C and MVAare salaries, and costs associated with in-patient’s overnight stay. Since the averagelength of stay gets reduced in the case ofMVA, the cost also gets reduced. (For detailssee Table 4). The study conducted in aMaternal Perinatal Institute in Lima, Perualso showed that as a result of reduced totaltime, the total mean cost per patient whichincluded cost of manpower, supplies and

administration was much lower for MVA ascompared to D&C with hospitalisation.

In India too the cost of abortion wouldbe much less if the MVA method were usedsince the apparatus is cheaper and it couldbe chemically sterilised. Moreover, sinceelectricity is not required, it can be usedeven in the rural PHCs where the supply ofelectricity is very erratic.B. MEDICAL ABORTION VS SURGICAL

ABORTION

In recent years a considerable debate isgoing on about the feasibility of introducingmedical abortion, using the drugsMifepristone and Misoprostol (RU486), as analternative to surgical abortion for thetermination of early pregnancy. Sincemedical abortion requires less extensiveinfrastructure than surgical abortion, it isargued that medical abortion can improveaccess to abortion and safety. There has alsobeen a debate on the side effects of Medicalabortion versus surgical abortion.

An international study of Mifepristone-Misoprostol medical abortion and surgicalabortion was held in China, Cuba and Indiafrom October 1991 to August 1993 in whichsix urban clinics participated. In this studywomen with a pregnancy duration of 56 dayscould enrol for either surgical or medicalabortion. The data collected from thiscomparative study showed that medicalabortion clients experienced more side effectsthan surgical abortion (Elul, Batya et al 1999).The disparity between the two groups wasparticularly pronounced for bleeding (exceptfor India where there were no significantdifferences by method) and pain. However,the study concluded that despite more reportsof side effects among women who had optedfor medical abortion, assessments of well- beingand reports of satisfaction at the exit interviewwere similar in both treatment groups.

Based on three studies conducted inIndia (including the already mentioned

15

international multicenter projects with sitesin China, Cuba and India) in the 1990s, ithas been concluded that medical abortionsare effective, acceptable to women, feasibleand safe (Coyaji, K. 2000). According to theauthor, since it is not possible in the nearfuture to create adequate infrastructure forsurgical abortions in India, medical abortioncould provide the alternative optionsespecially in village settings. The authorviews were that though the cost ofMifepristone was high, cost could be safelyand effectively reduced, by reducing the dosefrom 600mg to 200mg. Besides which, ascompared to medical abortion, under surgicalabortion one has to take into account otherexpenses like staff training and wages,operating room time etc. Moreover, theauthor was of the opinion that the cost ofMifepristone would drop considerably, onceIndia started manufacturing the drug locallyand included the drug in governmentprogrammes. Free distribution ordistribution at subsidised rates throughexisting family planning clinics would bemore cost effective.

In April 2002, the Drug Controller of Indiaapproved the manufacture of Mifepristone inIndia and three pharmaceutical companiesare already in the market. Prior to this, thetablet was being smuggled into the countrymainly from China and the gynaecologistswere illegally getting the supply from theagents. Obviously the tablet was veryexpensive (costing nearly a thousand rupees)and hence women who opted for the medicalabortions were also charged heavily.Currently, three pharmaceutical companiesare importing Mifepristone and packagingand marketing it in India and the price ofthe tablet has come down drastically - it nowranges around Rs 300 for 200mg. Includingthe cost of Misoprostol, which is available at20 to 30 rupees, the total cost of the tabletscomes well within 350 rupees and due tocompetition it is likely to fall further. Eventhough the cost of the tablets has reduced

considerably, the private doctors who areadministering medical abortions continue tocharge a high fee. A visit to some of theclinics in Delhi revealed that since not manywomen are aware of the cost of the tablets,the gynaecologists and doctors exploit thosewho opt for medical abortion. Some of thegynaecologists seem to offer abortionpackages to women and the charges vary fromRs 2000 to 3000, depending on the locationof the clinic and the clientele. This packageincludes an ultra sound test to make surethe abortion is complete.

Currently, Parivar Seva Sanstha iscarrying out a project, sponsored by theMinistry of Health and Family Welfare,Government of India to study the clinical andsocial behaviour of women acceptingtermination of early pregnancy up to 56 dayswith oral Mifepristone followed byMisoprostol. This aim of the project is to findout the efficacy of the drugs with the reduceddosage of Mifepristone (instead of 600 mg ofMifepristone, only 200 mg is given) and tounderstand the behaviour and attitude ofwomen. The Indian Council of MedicalResearch (ICMR) has already conducted astudy in medical college hospitals to find outthe efficacy of a reduced dosage ofMifepristone. The results were positive, inthe sense that the abortions were complete.This 18-month project commenced in April2002 and is being carried out at the MarieStopes clinics in Delhi, Agra and Jaipur.Though the final results of this project arenot available, according to the PSS thesuccess rate so far is fairly high. Since thegovernment sponsors the project, women whoopt for medical abortion under this project donot have to pay for the medicine. They haveto pay a consultation fee of Rs 50 and incurexpenses on other tests (e.g. pregnancy test)which may cost another 50 rupees. If thefindings of this project are positive, insteadof 600 mg of Mifepristone, 200 mg. may besufficient and this may reduce the cost evenfurther.

16

Although the abortion pill holds muchpromise, it has its problems. In particular,even though it can be sold only byprescription, in a country like India it is verydifficult to implement this and takestringent action against the lawbreakers. Aleading newspaper had recently reported therampant illegal over the counter sale ofMifepristone. This sounded alarm bells in thestate of Uttar Pradesh (Times of India, 6August 2002). Even though the tablets maycost around Rs 350, women may find thiseasier and a less expensive option thangoing in for surgical abortion. In addition theycan get this done in secrecy. The freeavailability and the unsupervised con-sumption of abortion pills can lead to severehaemorrhages and incomplete abortionresulting in life threatening emergency.Constant supervision and adequate backupfacilities of trained doctors is required.Furthermore women have to be very alert andaware, which is hardly the case in India. Infact if taking abortion pills without thesupervision of a gynaecologist leads tocomplication, medical abortion could proveto be more expensive.

V. ROLE OF THE STATE INIMPROVING THE ACCESS TO MTPSERVICES

The number of government approvedinstitutions in the country has increasedfrom 3294 in 1980-81 to 9759 in 2000-01, andthe number of terminations done per yearin these centres has gone up from 388,405to 721,428 during the same period. Theincrease in the number of legal abortionscould be partly due to the passing of the MTPAct, which has resulted in the increase inthe number of approved MTP centres. Duringthe last two decades, the number of womenin the reproductive age group has also goneup. Unfortunately, no data\information isavailable which could tell us whether thenumber of abortions per woman hasincreased over the years. According to the

data collected in the two rounds of theNational Family Health Survey on thepregnancy outcomes of married women in theage group of 15-49, the percentage ofpregnancies resulting in induced abortionhas increased marginally from 1.3 in 1992-93 to 1.7 in 1998-99 (IIPS, 1995 & IIPS, 2000).(Since the cases of induced abortions aregenerally suppressed by women, or may bereported as spontaneous abortions, thespontaneous abortions are grosslyunderestimated in the surveys and henceshould be interpreted with caution).

It is fairly well known that that theselegal abortions form only a small proportionof the total abortions taking place in thecountry. It is estimated that the number ofillegal abortions is 2 to 6 times more commonthan legal abortions. What are the reasonsfor this? The lack of awareness about theavailability of safe abortion services and thelack of privacy and the impersonalatmosphere in government run clinics aresome of the factors responsible for thisphenomenon. Besides this, the availabilityof the government approved MTP clinics isinadequate. Firstly, the availability ofabortion services varies widely across states.Almost half of the facilities for safe abortionsare concentrated in four states(Maharashtra-21 per cent, Gujarat-12 percent, Tamil Nadu-10 per cent and WestBengal-7 per cent), which accounts for only28 per cent of the country’s population. Thereis also a concentration of these centres inthe cities, though more than 70 per cent ofIndians live in the rural areas.

The non-availability of authorised clinicsin the rural areas and lack of financialresources to reach the clinics in urban areasis one of the reasons for women living in thevillages opting for illegal abortion. For ruralwomen the Primary Health Centre isprobably the nearest place where they canavail safe abortion services at a reasonablecost (even though in government facilitiesthe services are free there could still be some

17

medical officer trained in MTP, 22 per centof the PHCs are providing MTP services. Thisis possible because in many states if thePHC does not have a doctor trained in MTP itis a common practice to arrange for doctorsfrom the CHCs to visit the PHCs on aparticular day (may be once everyweek\fortnight) and carry out abortions.

According to the studies conducted byCORT in the four states of Gujarat,Maharashtra, Tamil Nadu and Uttar Pradesh,the main reason for not providing abortionservices in the PHCs and the CHCs turnedout to be a lack of trained doctors to conductthe procedure and non availability of requiredequipment (Khan, M.E. et al 2001). Otherstudies have also focussed on the inadequacyof trained manpower and equipment to carryout abortion services in the rural areasthrough the public health care system andthe lack of funding for the maintenance andexpansion of abortion services (RavindranT.K.S and R.Sen, 1994 and Jesani, A., andA.Iyer 1993). The CORT studies concludedthat the vast gap between demand and supply

expenditure). However, most of the PHCs donot have the facility for conducting MTPs.According to Phase 1 of the Facility Surveyconducted in 1999 in 221 districts, hardly 3per cent of the PHCs in the country areproviding MTP services (IIPS, 2001). TheFacility survey shows that there are widevariations across the states in theavailability of medical officers and the PHCsoffering MTP services (Table 5). It isinteresting to note that states like TamilNadu and Goa respectively have 35 per centand 59 per cent of PHCs with at least onemedical officer trained in MTP, but only 2 percent and 8 per cent of the PHCs respectivelyare providing abortion services. This clearlyreflects the mismatch between both theavailability of skilled manpower and theinfrastructure facilities. It is quite possiblethat in these PHCs although the MedicalOfficers are trained, they are not able toprovide the services because the PHCs maynot have proper buildings and other facilities.On the other hand, in the state of Punjab,although only 10 per cent of the PHCs have a

Table 5. Availability of MTP Services at PHCsSl. States/Union % of PHCs having at % of PHCs having % of PHCsNo. Territories (UTs) least one medical suction aspirator giving services

officer trained in MTP in MTP1 Andhra Pradesh 14 15 22 Assam 14 7 83 Bihar 6 7 14 Delhi 0 20 205 Goa 59 35 186 Gujarat 14 40 17 Haryana 4 21 18 Himachal Pradesh 14 18 149 Karnataka 10 13 810 Kerala 18 8 411 Madhya Pradesh 3 3 212 Maharashtra 17 28 113 Orissa 9 21 1

18Continued....

is largely due to lack of proper planning andallocation of resources. In the opinion of theauthors all the ‘A’ type Post Partum (PP)Centres that have adequate case loads couldbe converted into training centres. Todesignate an A type PP centre as an abortiontraining centre a maximum of Rs 2000 peryear would be required (Khan, M.E. et al2001). Though these studies were done inthe mid- 1990s, nothing much has changedsince then. The first phase of the FacilitySurvey conducted in 1999 also revealed thatonly 13 per cent of the PHCs in the countryhad at least one medical officer trained inMTP. In Tamil Nadu the situation seemedslightly better with 35 per cent of the PHCshaving medical officers trained in performingMTP (Table 5).

Similarly, only 16 per cent of thePHCs covered by the Facility Survey hadMTP equipment like suction aspirators,though the situation was somewhatbetter in states like Gujarat (40 percent) and Punjab (49 per cent). Thisreveals the apathetic attitude of thegovernment towards expansion ofabortion services and attempts atimproving the accessibility of safeabortion services.

Since 1991-92, the central governmenthas been allocating only Rs150 lakhs per year

for the abortion programme. Though in 1995-96 Rs 980 lakhs was requested for increasingthe abortion centres and strengthening theservices, but because of the resource crunchagain only Rs 150 lakh was allocated for theabortion programme (Khan,M.E. et al 2001).After the initiation of the Reproductive &Child Health (RCH) programme in 1997-98,Medical Termination of Pregnancy becameone of the important components of the RCHprogramme. Since then, in the budgetdocuments the allocation of funds for the MTPprogramme has not been shown separatelyand been included as a part of the RCHprogramme. Now under the 10th Five YearPlan, an amount of Rs 1.20 crores has beenallocated as transfer to states in the year2002-03 (Budget Estimate 2002-03)exclusively ear marked for MTP services(Ministry of Health and Family Welfare2002-03).

In an effort to expand and strengthensafe abortion services, under the RCHprogramme the government has taken someinitiatives. For instance, to meet theshortage of trained manpower in PHCs/CHCsand sub-district hospitals, the scheme of SafeMotherhood Consultants are beingintroduced. Under this scheme, the centralgovernment releases funds to states andUnion Territories for engaging privatedoctors trained in MTP techniques, to visit

19

14 Punjab 10 49 2215 Rajasthan 2 18 416 Tamil Nadu 35 17 217 Uttar Pradesh 4 19 118 West Bengal 3 3 1

All India (Incl.other States & UTs) 13 16 3

Source : Facility Survey, Phase-I, 1999, International Institute for Population Sciences, Mumbai

Sl. States/Union % of PHCs having at % of PHCs having % of PHCsNo. Territories (UTs) least one medical suction aspirator giving services

officer trained in MTP in MTP

Table 6. State/UT wise Allocation of Funds for SM Consultants and Supply of MTPEquipment under RCH Program

Sl.States

MTP Set # SM Consultant - FundsNo No. of Kits Estimated Value (Rs) released - in lakhs

1 Andhra Pradesh 10 65000 7.442 Arunachal Pradesh 3 19500 1.203 Assam 10 65000 24 Bihar 7 45500 05 Jharkhand 3 19500 06 Goa 1 6500 07 Gujarat 10 65000 10.088 Haryana 10 65000 159 Himachal Pradesh 3 19500 0.5010 J & K 3 19500 1.8011 Karnataka 10 65000 812 Kerala 10 65000 013* Madhya Pradesh * 10 65000 214 Maharashtra 10 65000 515 Manipur 3 19500 216 Meghalaya 3 19500 0.6017 Mizoram 1 6500 20.7418 Nagaland 3 19500 019 Orissa 10 65000 7.5620 Punjab 10 65000 021 Rajasthan 10 65000 022 Sikkim 1 6500 3.6023 Tamil Nadu 10 65000 024 Tripura 1 6500 025 Uttar Pradesh 10 65000 184.6526 West Bengal 10 65000 41.8827 And. & Nic. Island 1 6500 028 Chandigarh 1 6500 029 Dadra & Nagar Haveli 1 6500 1.8030 Daman & Diu 1 6500 031 Lakshadweep 1 6500 032 Pondicherry 1 6500 0.2033 Delhi 1 6500 034 Reserves 1 6500 -

Total 180 1,170,000 316.05Note (*) : Includes Chattisgarh(#): MTP Set worth Rs 6500 includes S. S. Bowl (18-20 inch diameter), Sponge Holding Forceps, IS:7735,Sim’s Speculum, IS: 6112, Anterior Vaginal Wall Retractor, IS: 5849, Uterine Sound, IS: 5829, Vulsellum,IS 6114, Curette (Double ended), Sharp / Blunt, IS: 6505, Ovum Forceps, IS: 6578, Dissecting Forceps, IS:3643, Dilators (Hegar’s pattern), I mm to 12 mm, IS: 6584, Suction Machine (Facility for negative suction upto760 mm, with safety device), IS: 7080, Karman’s Cannula (No. 6,7,8), IS: 8313 (4 Sets each)(Source : From the records of the Ministry of Health and Family Welfare, Government of India.)

20

these institutions once a week or at leasttwice a fortnight on a fixed day for performingMTPs. These doctors were initially paid atthe rate of Rs 500 per day. Now the amounthas been increased to Rs 800 per day. Since1997-98 (till Nov 2002) the government hasreleased Rs 316.05 lakhs to the states andUnion Territories (Table 6).

However, the states and Unionterritories have so far utilised only one thirdof the allotted amount and in fact very fewstates have reported expenditure under thisaccount. This indicates either the non-availability of trained manpower that iswilling to work in rural areas at this rate orlack of other infrastructure to implement thisscheme in the PHCs. It is indeed hearteningto note that the government has taken adecision to train all the medical officers ofthe PHCs in MTP. The Facility Survey results(Table 5) indicate that this would solve onlypart of the problem. In addition to trainingthe doctors, other facilities and adequateinfrastructure at the level of PHCs and CHCsshould also be improved. If the facilities atthe PHCs and CHCs were improved, perhapsmore women would access these facilitiesrather than spend a lot of money at privatefacilities. By switching over to methods likeMVA, the cost to the government would alsobe reduced since the apparatus required forMVA is cheaper, there is no need ofelectricity and it can be sterilised chemically.

In order to improve the availability ofabortion services, MTP equipment is beingprocured centrally and provided to Districthospitals, first referral units (FRUs), CHCsand PHCs through their respective medicalstore depots. Since the inception of the RCHprogramme i.e. since 1997-98, thegovernment has supplied 180 MTP sets worthRs11.70 lakhs (Table 6). The estimated valueof each set is Rs 6500. The item descriptionof the MTP set is presented along with thetable. While most of the major states havereceived 10 sets, states like HimachalPradesh, Jammu & Kashmir, Meghalaya,

Manipur and Nagaland have so far receivedonly 3 sets. All the other smaller states andUnion Territories have got just one set each.Considering the current status of availability,this is hardly going to improve the situation.

In addition to the problem of non-availability of trained manpower and theavailability of equipment, there is also amismatch between the availability of traineddoctors/specialists like anaesthetists andthe availability of infrastructure like OT ina number of CHCs (NCAER, 2002)

VI. HEALTH INSURANCE SCHEMESAND ABORTION

It has been well documented thathouseholds face enormous financial burdensin the form of out of pocket expenses to payfor health care and health spending in Indiagoes mostly to private facilities (NSSO, 1998,Sundar, 1995, Sevaraju, 2000). This hassignificant adverse implications for theeconomic well being of the affectedhouseholds, especially the poor households.The failure of the Indian public health caresystem to provide quality care to the peopleis to be blamed for this excessive financialburden on poor households. Public healthcare in the country suffers from underfunding and accessibility problems and as aresult people are forced to depend on theprivate health care sector, which is relativelymore expensive. Keeping the financialburden on the households within areasonable limit is a matter of policy concern.The solution for this could be found either byimproving the quality and accessibility ofpublic health services, or through theprovision of health insurance schemes.

In India, given the resource crunch it isnot possible to expect any drasticimprovement in the public health servicesin the near future. In fact severe resourceconstraints have led the policy makers toconsider alternative sources of financing thepublic health care system and the HealthPolicy 2002 ‘recognises the practical need

21

for levying reasonable user charges forcertain secondary and tertiary public healthservices, for those who could afford to pay.’

As far as abortion services are con-cerned, the other option of insuranceschemes is also almost non-existent in thecountry. In fact in India health insurance isyet to pick up in a big way. The MaternityBenefit Act, which was enacted as early as1961, provides leave benefits for womenworkers during the six weeks immediatelyfollowing the day of delivery, miscarriage orabortion. This maternity benefit is to be pro-vided to all women on completion of 80 work-ing days during the preceding twelve months.Currently, the major health insuranceschemes are either state run schemes forthe employees in the organised sector Em-ployees State Insurance Scheme (ESIS) orthe schemes for government employees likethe Central Government Health Scheme(CGHS) and the Railway Health InsuranceScheme for railway employees. Besidesthese, there are public sector insuranceschemes like the Mediclaim Health Insur-ance Plan of the General Insurance Corpo-ration, the Senior Citizen Plan of the UnitTrust of India and schemes like Asha Deepof the Life Insurance Corporation of India.There are also community based health in-surance schemes primarily for workers out-side the formal sector (e.g. SEWA ofAhmedabad, Sevagram of Warda, CINI ofDaulatpur in West Bengal etc.). Althoughmost of these community based health in-surance schemes provide preventive, promo-tive and curative health services, includingMother & Child Health (MCH) activities, theydo not seem to cover MTP services.

Of the various schemes meant for theemployees of the organised sector the ESIS,CGHS and the Railway Health Scheme pro-vide MTP services for women covered undertheir schemes in the hospitals run by them.In the case of women employees who areinsured under the ESIS scheme, both cashand medical benefits are provided for mater-

nity related health care including MTP. TheESIS, launched in 1948 is essentially a com-pulsory social security benefit to workers inthe industrial sector. The ESIS covers nearly80 lakh persons (employees and their fami-lies) and this includes 14 lakh women (ESIS,2001- 02).

In the ESIS hospitals 14,878 MTPs havebeen performed during the year 2001-02.Since MTP services are offered only as a fam-ily planning method (ESIS, 2001-02) thenumber of MTPs performed is shown as a partof the ‘achievements under their FamilyWelfare Programme’. In fact, discussionswith a gynaecologist in one of the ESIS hos-pitals in Delhi revealed that they offer freeabortion services even to those women whoare not covered under their scheme providedthey are willing to undergo sterilisation. Thesame is true of the CGHS Maternity andGynaecology Hospital in south Delhi. Whilethe MTP services are available to all thosecovered under the scheme, for outsiders,abortion services are available only as a fam-ily planning measure i.e. with the accep-tance of sterilisation, as this would enablethem to full fill their ‘quota’ of sterilisation.

Even though a target free approach hasbeen officially announced, in practice thereare indirect pressures to meet the target.

The Mediclaim plan, which is run by theGeneral Insurance Corporation (GIC) of In-dia, which is meant for the general public,covers only hospital care. This scheme by andlarge caters to the upper middle and high-income group and as on March 2002 morethan 70 lakh persons are receiving coverunder the scheme (Annual Reports of the foursubsidiary companies of GIC-2001-02). Therehas also been a tremendous increase in en-rolment for the Medical Claim policy. How-ever, under this policy only hospitalisationexpenses are covered, while routine out pa-tient care is excluded. The policy, however,not only excludes reimbursement of expensesagainst certain diseases, but also any ex-

22

Table 7. Salient Features of Important Health Insurance SchemesSl. Type of Health Coverage, Age & Details about theNo. Insurance Scheme and Sum Insured inclusions and Exclusionsyear of commencement

1

2

3

4

Mediclaim,1986 GeneralInsurance Corporation(individual\family\group)

Jan Arogya,1996, GIC(Individual\family)

Asha Deep, 1995 LifeInsurance Corporation

Central GovernmentHealth Scheme

Individual aged 5-75 &Family 3 months to 75years. Rs15,000 to5,00,000

Age group up to 70years Sum assured Rs5000

Individual aged 18-50years Rs 50,000 to3,00,000

Central governmentemployees (current &retired) and families

Only hospitalisationcoverage with exclusionof pre-existing conditionsPregnancy & Abortionnot included

Same as above

Endowment policy with coverageof four ailments- cancer,paralytic strokes, renalfailure and coronary heartdiseases

All types of services, includingMTP.

penses related to pregnancy. Pregnancy andchildbirth are covered only under the groupinsurance scheme as a benefit policy. TheGIC in its effort to expand coverage intro-duced another policy in 1996 called the JanArogya Bima Policy, to cater to the healthneeds of people belonging to lower incomegroups. Since the annual premium is nomi-nal, it has attracted a lot of people (around3.5 lakh people as on 31st March 2002). Thisscheme also excludes pregnancy, childbirthand voluntary termination of pregnancy.

Several NGOs and governments world-wide have started micro- credit schemes forvulnerable groups as an effective tool for pov-erty reduction. To plug the erosion of incomeand reduce indebtedness for health careneeds, some NGOs like SEWA (Self-EmployedWomen’s Association), have introducedhealth insurance schemes for their mem-

bers. It is rather surprising that even thehealth insurance scheme of SEWA which isspecially designed for women, covers deliv-eries but does not include abortion care(Gumber Anil and Veena Kulkarni, 2000).

Given the current scenario of theavailability of health facilities and theacceptors of abortion services, is it pos-sible or even feasible to introduceschemes to include insurance cover forabortion care? In a country where ille-gal abortions are rampant, introductionof insurance schemes may encouragemore women to opt for an approved MTPclinic even if it proves to be more ex-pensive.

Some studies point out that a number ofwomen seek abortion services without theknowledge of their husbands and other fam-

23

Continued....

Source : Health Insurance For Informal Sector: Problems and Prospects by Anil Gumber. Paper prepared forIndian Council for Research on International Economic Relations, New Delhi, November 2002

Sl. Type of Health Coverage, Age & Details about theNo. Insurance Scheme and Sum Insured inclusions and Exclusionsyear of commencement

5

6

7.

Railways HealthInsurance Scheme,1948

Employees StateInsurance Scheme,1948

SEWA, Ahmedabad,Gujarat. Union startedin 1972,HealthProgramme in 1984

Railway employeesand families (currentand retired)

Any employee andhis/her family in anorganised sector withmonthly wages underRs 6500

Union of selfemployed womenHelps to organisecooperatives ofvarious traders,provides creditfacilities and healthcare

Delivery of all types of servicesincluding delivery and MTP,through hospitals anddispensaries located in Grade Astations

Medical and cash benefitsthrough the dispensaries andhospitals. Covers maternitybenefits including MTP. MTP isdone free of cost in the ESIShospitals. This extends to noninsured persons also withacceptance of sterilisation

SEWA’s health insurancescheme functions in co-ordination with LIC and NewIndia Assurance Company.Offers comprehensive healthinsurance package to addresswomen’s basic needs. Coversdeliveries but not abortion.

ily members (Gupte Manisha et al 1997 andSinha, A.K et al 1998). The socio-culturalfactors like the stigma attached to abortioncompels women to trade off quality of care inorder to preserve confidentiality (Bandewar,Sunita 1997). Under such circumstanceswomen would be able to take advantage ofan insurance scheme, only if they have suf-ficient economic independence to join aninsurance policy, which also takes care ofabortion expenses.

The other important question is whetherit is feasible for insurance companies to ex-tend the coverage to include abortion care.This question is relevant today, since theinsurance sector has been privatised and anumber of private insurance companies

have already started operating in the coun-try. Any insurance scheme is based on theuncertainty of an event taking place. Giventhis principle of insurance, it may not be fea-sible for a health insurance plan like theMediclaim to include abortion expenses,without attaching some conditions (e.g. re-striction on the number of abortions per in-sured woman). In a country like India,where there are illegal abortions, in par-ticular since sex selective abortions arenot uncommon; the insurance companieshave to be careful about the legal aspectswhile handling claims against abortionexpenses. It may be possible to includeabortion expenses along with other mater-nity benefits in a community based insur-

24

ance scheme like the SEWA plan, whichbasically caters to women in the informalsector.

Based on the admittedly limited informa-tion available, we may conclude by saying itis of foremost importance to provide afford-able, safe and accessible MTP services towomen. In addition, if at least some of thecommunity based insurance schemes canalso cover MTP it would reduce the financialburden for women seeking abortion services.

VII. CONCLUDING REMARKS

A review of the available literature indi-cates that there is very limited data on thecost of abortion care in the country. The firststep should be to intensify research in thiscritical area of financing for abortion care.We need to know not only what abortioncharges are at the various types of MTP cen-tres, but also the household dynamics likethe source of financing the abortion etc. Inthe case of most of the surveys, the samplesize of the abortion seekers was too small todraw any conclusion. A well designed quan-titative survey, supplemented or rathercomplemented with qualitative researchtechniques like Focus Group Discussions,with the exclusive objective of capturing thevarious aspects of abortion including costand finance would serve a useful purpose forpolicy makers

From what little information is available,it is clear that even in the government fa-cilities, the abortion seekers had incurredsubstantial expenditure. The state has toreally look into this. Abortion seekers spend-

ing money on transport or medicine is un-derstandable, but many of them seemed tohave had to even pay fees in some form or theother while utilising public health facilities.

In the case of government approved MTPcentres, there does not seem to be any con-trol either over the quality of services or onthe charges for the abortion services. Sincethe approved centres are required to renewtheir license periodically, the respectivestate government could streamline the ac-tivities of these centres.

We need much better regulation of pri-vate medical practitioners as well as dis-semination of information to them so thatthose women seeking abortions are not ex-ploited financially. There is too much anec-dotal data, which suggests that doctors do nothesitate to unethically overcharge for ex-ample unmarried pregnant women, orwomen who are otherwise concerned aboutconfidentiality. Similarly, decline in theprices of drugs (e.g. for medical abortion) of-ten do not get translated into decline in thecosts of the service for women because doc-tors continue to charge the old rates. It hasbeen found that even in the government ap-proved MTP centres, unmarried girls seek-ing abortion are exploited and charged anexorbitant rate. As a result those who can-not afford the expense end up with thequacks. The main reason for unmarried girlsnot approaching the public facilities is thelack of privacy and confidentiality. If privacyand confidentiality can be ensured, some ofthe cases might consider attending public clin-ics.

25

Bandewar, Sunita, (1997) A Note on Abor-tion: Cause for Concern in India, Even 25 YearsAfter its Legalisation. Centre for Enquiry intoHealth and Allied Themes (CEHAT), SixthNational Conference of Women’s Movementat Ranchi, Bihar, December 28-30.

CEHAT, (2001) Women and Health Care inMumbai: A Study of Morbidity, Utilisation andExpenditure on Health care by the Householdsof the Metropolis.

Chakravarty Sayantan, (1996) ‘Abortion:The Double Death Syndrome’, India Today,August 11.

Chhabra Rami and Sheel C.Nuna n.d.,‘Abortion in India: An Overview’, VeerendraPrinters, New Delhi.

CORT, (1995) (Centre for Operations Re-search And Training), Situation Analysis ofMedical Termination of Pregnancy (MTP) Ser-vices in Gujarat, Baroda.

CORT (1996) (Centre for Operations Re-search And Training), Situation Analysis ofMedical Termination of Pregnancy (MTP) Ser-vices in Maharashtra, Baroda.

CORT (1997a) (Centre for OperationsResearch and Training), Situation Analysis ofMedical Termination of Pregnancy (MTP) Ser-vices in Uttar Pradesh, Baroda.

CORT (1997b) (Centre for OperationsResearch and Training), Situation Analysis ofMedical Termination of Pregnancy (MTP) Ser-vices in Tamil Nadu, Baroda.

CORT (1998) (Centre for Operations Re-search And Training), ‘Availability and Qual-ity of MTP Services in Gujarat, Maharash-tra, Tamil Nadu and Uttar Pradesh - An In-

REFERENCES

depth Study’ Paper Presented at the Inter-national Workshop on Abortion Facility andPost Abortion Care in the Context of RCH Pro-gram, March, 23-24.

Coyaji Kurus, MD, (2000) ‘Early MedicalAbortion in India: Three Studies and TheirImplication for Abortion Services’, Journal ofAmerican Medical Women Association; Vol. 55,No.3: 191-194.

Duggal Ravi and Suchetha Amin, (1989)‘Cost of Health Care - A Household Survey inan Indian District’, FRCH, Mumbai.

Elul Batya et.al. (1999) ‘Side Effects ofMifeprostone - Misoprostol Abortion VersusSurgical Abortion, Data from a trial in China,Cuba and India’, Contraception; 59: 107-114.

ESIS (2002) (Employees State InsuranceCorporation) 2001-02, Annual Report.

Ganatra, B. R. et al (1996), Induced Abor-tion in a Rural Community in Western Maha-rashtra: Prevalence and Patterns. Study con-ducted by the King Edward Memorial Hospi-tal and Research Centre, Pune.

George, Alex, Ila Shah and SunilNandraj, (1994) A Study of Household HealthExpenditure in Madhya Pradesh, FRCH, Mum-bai.

Government of India, Ministry for Health& Family Welfare, Annual Report 2001-02.

Government of India, Ministry of Health &Family Welfare, Performance Budget 2002-03.

Gumber Anil and Veena Kulkarni, (2000)Health Insurance for Workers in the InformalSector: Detailed Results from a Pilot Study- Con-tribution of the Informal Sector to the Economy.Report No. 5, NCAER.

Gupte, M, Sunita Bandewar and

26

 

Hemalata Pisal (1997) ‘Abortion Needs ofWomen in India: A Case Study of Rural Ma-harashtra’, Reproductive Health Matters, N05(9): 77-86.

IIHMR (2000) Financing Reproductive &Child Health Care in Rajasthan, Indian Insti-tute for Health Management Research,Jaipur.

IIPS (1995) National Family Health Sur-vey (NFHS-1) 1992-93, International Institutefor Population Science, Mumbai.

IIPS (2000) National Family Health Sur-vey, (NFHS-2) 1998-99, International Insti-tute for Population Science, Mumbai.

IIPS (2001) Facility Survey (Under Repro-ductive and Child Health Project) Phase - 1,International Institute for Population Sci-ence, Mumbai.

Jesani, A. and A. Iyer, (1993) ‘Womenand Abortion’, Economic and Political Weekly,Vol.— Nov. 27, pp. 2591-2594.

Jowett, M, (2000) ‘Safe Motherhood: In-terventions in Low-Income Countries: AnEconomic Justification and Evidence of CostEffectiveness’ Health Policy Vol.53 No.3pp. 201-228.

Khan, M.E., Sandhya Barge and NayanKumar (2001), ‘ Availability and Access toAbortion Services in India: Myth and Reali-ties’, Paper Presented at the IUSSP Confer-ence in Brazil.

Maitra, N. (1998) ‘Unsafe Abortion: Prac-tices and Solutions’, Paper presented at theInternational Workshop on Abortion facilitiesand post Abortion Care in the context of RCHProgram, March 23-24, New Delhi, Organisedby the Centre for Operation Research andTraining.

NCAER (2002), Workforce ManagementOptions and Infrastructure Rationalisationof Primary Health Care, Unpublished Report,National Council of Applied Economic Re-search, New Delhi.

NSSO (1998), Morbidity and Treatment

of Ailments, Report No. 441, National SampleSurvey Organisation, Government of India,NSSO, Department of Statistics, New Delhi.

Passano Paige (2002), ‘ Legal but notAvailable: The Paradox of Abortion in India’,Mannish, Issue No: 126.

PSS (1999-2000), ‘Perception & Experi-ence of Abortion seekers Study Conductedin Delhi, Calcutta and Lucknow’ Parivar SevaSanstha, New Delhi.

PSS (2001) Parivar Seva Sanstha(2000-01) Annual Report.

PSS (2002), ‘Rapid Assessment of Abor-tion Clients - a qualitative Case Study inSelected Districts of Orissa’, UnpublishedReport, Parivar Seva Sanstha, New Delhi.

Ravindran, T. K. S. and R. Sen (1994),‘Service Delivery System in Induced Abor-tion: A Report’, Report of a workshop organ-ised by the Parivar Seva Sanstha in Febru-ary 1994 at New Delhi, with support providedby the Ford Foundation.

Sevaraju, V. (2000) ‘Health care Expen-diture in Rural India: A Micro Perspective’,Paper Presented at International seminar onHuman Development, New Delhi, 27-29 No-vember.

Sinha, R., et al ‘Decision Making andAcceptance and Seeking abortion of Un-wanted Pregnancy’ Paper presented at theInternational Workshop on Abortion facilitiesand Post Abortion Care in the context of RCHProgram, March 23-24, New Delhi, Organisedby the Centre for Operation Research andTraining.

Sundar Ramamani (1995), ‘HouseholdSurvey of Health Care Utilisation and Expen-diture’, Working Paper No: 53, NCAER, NewDelhi.

Sundar Ramamani; Ajay Mahal andAbhilasha Sharma (2002), ‘The Burden of IllHealth among the Urban Poor: The Case ofSlums and Resettlement Colonies in Chen-nai and Delhi’, NCAER, New Delhi.

Times of India (2002),’Abortion Pill SoundsAlarm bells in UP’, August 6, New Delhi.

27

ABOUT THE AUTHOR

Ramamani SundarRamamani Sundar holds a Masters Degree in Econo-

mics from the Delhi School of Economics. She is currentlyworking as a Senior Economist with the National Councilof Applied Economic Research, New Delhi. For the past 15to 20 years she has been working as a researcher in thefield of Health Economics, Reproductive Health and Demo-graphy.

Ramamani Sundar has several publications to hercredit including the NCAER Working Paper on HouseholdSurvey of Health Care Utilization and Expenditure and TheBurden of Ill Health Among the Urban Poor : A Case of Slumsand Resettlement Colonies in Delhi and Chennai ”.

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