FEATURE
Physicians’ and non-physicians’ views about provision of medical abortion by nurses and AYUSH physicians in Maharashtra and Bihar, India Rajib Acharya,a Shveta Kalyanwalab a Associate, Population Council, New Delhi, India. Correspondence: [email protected] b Independent consultant, New Delhi, India
Abstract: There is only limited evidence on whether certified and uncertified health care providers in India support reforming the Medical Termination of Pregnancy (MTP) Act to expand the abortion provider base to allow trained nurses and AYUSH physicians (who are trained in Indian systems of medicine) to provide medical abortion. To explore their views, we conducted a survey of 1,200 physicians and other health care providers in Maharashtra and Bihar states and in-depth interviews with 34 of them who had used medical abortion in their practices. Findings indicate that obstetrician-gynaecologists and other allopathic physicians were less supportive than non-physicians of nurses and AYUSH physicians providing early medical abortion. The physicians did not think that these providers would be able to assess women’s eligibility for medical abortion correctly. In contrast, the majority of non-physicians found task shifting of medical abortion provision to trained nurses and AYUSH physicians acceptable, and they were confident that these providers would be able to provide medical abortion as safely and effectively as trained physicians. Assuming the reforms are passed, efforts will need to be made by government and medical professional bodies to train these new providers to undertake this role, prepare the health infrastructure to include them, and create an environment, including among physicians, that is conducive to enabling non-physicians to provide medical abortion. © 2015 Reproductive Health Matters Keywords: abortion law and policy, medical abortion, task shifting, mid-level providers, AYUSH physicians, nurses, India While abortion has been legal in India since the enactment of the Medical Termination of Pregnancy (MTP) Act of 1971 and medical abortion (MA) has been approved since 2002,* women in
India continue to have abortions outside of registered settings and/or from uncertified providers mainly because:
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availability of legal abortion services is concentrated in and around urban areas, even though more than 70% of the population live in rural areas, where demand for abortion is high; there is an acute shortage of trained providers, heightened by government policy of restricting provision to trained physicians (Ob/Gyns and general physicians); and even though mandated in government policy, most of the public primary care facilities are not equipped to provide abortion services because of lack of trained providers and lack of availability of equipment and medical abortion pills.
*Abortion is legal in India when performed by a certified medical practitioner in a hospital or institution approved by the Government. Obstetrician-gynaecologists (Ob/Gyns) are certified by way of their training. Other doctors with a degree equivalent to MBBS or higher can provide abortions up to 12 weeks of pregnancy LMP if they have received theoretical and practical training involving observing, assisting and performing a total of 25 abortions in a registered facility. Only Ob/Gyns can provide abortions of pregnancies between 13–20 weeks. Certified medical practitioners can also prescribe medical abortion pills up to nine weeks of pregnancy in an unapproved clinic, provided they have referral access to a facility approved for abortions.
In rural and inaccessible areas, where access to approved services and trained physicians is
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Doi: 10.1016/S0968-8080(14)43787-X
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limited, informal/untrained providers are the most accessible source of abortion services,1 and abortionrelated morbidity remains high. While the current incidence of abortion-related complications in India is not known, the latest available estimates, for 2001–03, suggested that complications arising from unsafe abortion accounted for some 8% of maternal deaths in the country.2 To reduce maternal mortality due to unsafe abortion, the World Health Organization has recommended task shifting to increase the cadre and number of personnel, including non-physicians such as nurses and nurse-midwives, who are trained and equipped to provide abortion services at the primary care level.3 Evidence from both low- and high-income countries shows that task-shifting from physicians to other health professionals – including nurses, nurse-midwives and other non-physicians, as well as physicians trained in Indian Systems of Medicine – has been a successful model for expanding abortion services without compromising patient safety and satisfaction,4–10 and that women are supportive of and satisfied with the provision of abortion services by these providers. Moreover, non-physicians are generally more likely than trained physicians to work in remote and under-served areas of India, in close proximity to the community, and to offer more affordable services.7,11 In fact, many of these uncertified providers do provide both surgical and medical abortion in response to demand from the community.12–14 Thus, formally expanding the range of medical abortion providers in India is both a safe and feasible option. India has a large work force of non-physician providers and AYUSH physicians* who can be trained and certified to provide abortion services. In 2011, India had 628,634 registered AYUSH physicians and 1,406,006 trained nurses.15 Recognising the potential for expanding the abortion provider base through this large number of providers, a government-appointed expert committee, comprised of academics, policy makers, members of the Federation of Obstetric and Gynaecological Societies of India (FOGSI) and other stakeholders, recommended amendments *AYUSH encompasses physicians trained in Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy. A separate Department of AYUSH has been set up in the Ministry of Health and Family Welfare, Government of India, for the provision of services relating to these officially recognized Indian Systems of Medicine.
to the existing MTP laws in 2009 to include nurses and AYUSH physicians to be trained to provide abortion services and certified by approved training centres. The amendments are under active consideration by the Ministry of Health and Family Welfare at this writing. In spite of government interest in task-shifting of abortion services to non-physician providers, however, there is little evidence either of the extent of these providers’ own interest in providing medical abortion or the perspectives of Ob/Gyns and other physicians on training these cadres as abortion providers. The few studies in India on these questions, published between 2005 and 2009, found that trained physicians typically opposed the expansion of the provider base to include non-physicians.16,17 One study found that only 40% of 413 Ob/Gyns interviewed believed that non-physician providers could be trained to provide medical abortion.16 A facility-based study published in 2009 found that only 34% of 54 Ob/Gyns and 58% of 88 general physicians interviewed were supportive of non-physicians’ participation in the provision of early medical abortion; in contrast, however, 74% of 263 nonphysicians interviewed expressed interest in being trained themselves to provide medical abortion.11 Given the continuing unmet need for more trained abortion providers and the upcoming amendment to the law, it is important to find out what the views of Ob/Gyns and other physicians, as well as a range of non-physician health care providers are, as regards expanding the provider base. This information may help the government and other stakeholders plan a strategy to work with trained physicians in order to create an environment, including among physicians, conducive to smooth implementation of the amended law. The objective of this paper is to shed light on the views of a range of health care providers on the provision of medical abortion by nurses and AYUSH physicians. Study setting The study was conducted from November 2009 to May 2010 in four selected districts in the state of Maharashtra, a more developed state with better health infrastructure than the national average, and four districts in the state of Bihar, a relatively poorly developed state with a poor health infrastructure. The two states were selected because they vary in socioeconomic and demographic characteristics and sexual and reproductive health 37
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indicators and represent two contrasting scenarios in the country, and their total population size is not very different. Thus, for example, the percentage of women of reproductive age who were literate in Maharashtra (76%) was twice that observed in Bihar (38%); similar differences, respectively, were found in contraceptive prevalence (67% vs. 34%) and unmet need for contraception (10% vs 23%).18 As regards abortion, government statistics from 2009–2010 show that about 86,339 abortions were conducted in registered facilities in Maharashtra and 19,509 in registered facilities in Bihar. Statistics on unregistered abortions are not available by state. However, in Bihar there are only 146 approved facilities for abortion services compared to 2,846 in Maharashtra, which goes a long way to explaining why these numbers are so different between the two states.19 Design and methodology Data for this paper come from a larger descriptive study focusing on the perspectives and experiences of a wide range of providers in rural and urban areas in both states with regard to medical abortion. The study focused on five categories of providers: Ob/Gyns, general physicians (irrespective of whether they were certified to provide abortions), nurses and auxiliary nurse-midwives (ANMs), AYUSH physicians, informal providers (including rural medical practitioners, or RMPs*) and traditional birth attendants (dais). It included both a survey using a structured questionnaire and in-depth interviews and was conducted in four districts of each state. The districts were selected to be representative of different regions of each state. A detailed description of the sampling process can be found in another article, with data from the same study, on certified providers’ knowledge, attitudes and practices of medical abortion.20 Those who consented to participate (response rate 89−92% for the different categories of providers) were interviewed using a questionnaire that employed structured, closed-ended questions, presented with their answers below. This paper focuses on the survey data drawn from a total of 1,200 health care providers, consisting of 270 certified abortion providers (240 Ob/Gyns and 30 general physicians), 210 *Rural medical practitioners usually learn their skills in the course of assisting trained medical doctors.
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uncertified allopathic physicians with MBBS/ MS/MD degrees, and 240 each of AYUSH providers, nurses/auxiliary nurse-midwives, and informal providers (RMPs and dais). It also draws on data from in-depth interviews with 34 providers: 19 from Bihar and 15 from Maharashtra. Respondents (36) for in-depth interviews were selected randomly from providers who responded to the survey and reported that they had used medical abortion in their practice.
Findings Characteristics of providers The median age of respondents was 41 years (range 19–81), with physicians somewhat older than non-physicians (43 vs. 38 years). Among physicians certified to provide abortion, 37% had a post-graduate degree in medicine or surgery and 52% had a post-graduate Diploma in Gynaecology and Obstetrics. Among non-certified allopathic physicians, 70% had an MBBS degree and the rest had a post-graduate degree in medicine or surgery. The sample covered 83 (35%) Ayurved, 151 (63%) homeopaths, and 6 Unani physicians with Bachelor of Ayurveda, Medicine and Surgery, Bachelor of Homeopathic Medicine and Surgery and Bachelor of Unani Medical Science degrees, respectively. The survey also covered 85 nurses with a degree or diploma in nursing and 155 auxiliary nurse-midwives (ANMs) with 12 years of schooling on average. RMPs and dais were slightly less educated than ANMs – on average they had completed ten years of schooling. The general awareness of medical abortion (that is, awareness that abortion can be induced using a combination of mifepristone and misoprostol) was universal among the certified abortion providers, and among 77% of non-certified allopathic providers and 59% of nurses and ANMs. Awareness of medical abortion was far more limited among AYUSH physicians and informal providers – 47% and 26%, respectively. Expansion of abortion services All providers, irrespective of whether they had ever provided abortion services, were asked to suggest ways in which access to abortion services could be expanded. The question was openended and providers’ spontaneous responses were recorded. Table 1 shows the various suggestions; key among these were increasing the number of trained providers (MBBS physicians
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and Ob/Gyns − 23%−48% in Bihar and 63%−86% in Maharashtra), increasing the number of registered facilities in which abortions may be conducted (37%−65% in Bihar and 32%−60% in Maharashtra) and expanding community awareness about the location of abortion services (33%−52% in Bihar and 34%−44% in Maharashtra). Physicians were somewhat more likely than non-physicians to make each of these three suggestions for ways of expanding services. During the in-depth interviews, providers reiterated the view that training the cadres of providers permitted under the current law (MBBS and Ob/Gyn) was an effective way of expanding services. “In my opinion… we are falling very short of the required numbers of trained providers. We have to increase the number of specialists. All MBBS trained doctors should be given special compulsory
training in abortion techniques and all medicos joining the health services should be compulsorily posted in rural areas. This will make it possible to provide abortion services at village level.” (Male, certified MBBS physician, rural Maharashtra) “There is a need for special training to make these [abortion] services better.… The number of service providers as well as government facilities should be increased. ” (Male, Ayurved physician, rural Bihar) “For this, training must be provided to the doctors nearby and to those who are good and educated, and not to [rural medical practitioners]. They do not have any knowledge. Training needs to be given on the correct treatment to be given to a woman who comes to a provider bleeding.” (Female, ANM, rural Bihar) 39
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Several respondents also suggested that women should be given information on the availability and location of safe abortion services. “There are a lot of women who don’t know about [medical abortion] pills. They wait for three or more months. If this information could be spread among women in villages through mass communication then they may come directly to us and ask for medical abortion. Women should be told to contact only a trained person instead of going here and there, or to a medical store or a nurse.” (Female, Ob/Gyn, urban Bihar) “While there should be proper training [of providers] there should also be advertisements through the electronic media, that tell people what is harmful and appeal to women to take tablets only from well-trained doctors.” (Female, Ob/Gyn, rural Maharashtra) “Health committees in villages should be more actively engaged in providing mass education about these matters. As it is, government-sponsored health education campaigns do emphasize that ‘The shorter the duration of the pregnancy, the safer the abortion’. But I do not think people take this message seriously. They wait till the pregnancy is 15–20 weeks and then come requesting an abortion! This tendency needs to be changed immediately so that more abortions can be done safely.” (Male, Certified MBBS physician, rural Maharashtra) Fewer physicians than non-physicians (11%–24% vs. 8%–35% in Bihar and 4%–14% vs. 7%–28% in Maharashtra, respectively) suggested allowing non-physician providers to provide surgical and/or medical abortion in both the survey and in-depth interviews. “Training should be given to all working in the health sector. Homeopath and Ayurved doctors also should be given training so that abortion services can be available at village level. Homeopath and Ayurved doctors do go to rural areas and if training is given to them, women from villages would benefit… ” (Female, ANM, rural Maharashtra) “It would be beneficial to give training to nurses and homeopathic doctors because there are subcentres where only nurses are appointed… Training should be given to each nurse appointed at sub-centres so that women in the village can avail of services without spending money on travelling.” (Female ANM, rural Maharashtra) 40
“Emphasis should be given to educate nurses or other providers so that they can be ready to handle the complications [of abortion]. They should be trained to perform surgical abortion also so that they could provide surgical services smoothly.” (Female, Ob/Gyn, rural Bihar) With a few notable differences, providers from Bihar and Maharashtra tended to make similar suggestions for expanding services. Providers from Maharashtra were far more likely than providers from Bihar to suggest increasing the number of trained providers and abortion facilities; the only exceptions were Ob/Gyns from Bihar, who were more likely than their counterparts in Maharashtra to suggest increasing the number of facilities providing abortion services (65% vs. 50%). Physicians from Bihar were more likely than their counterparts from Maharashtra to suggest allowing non-physicians to provide surgical or medical abortion – 11% vs. 7% and 24% vs. 14%, respectively. Safety and efficacy of medical abortion In order to understand the views of providers about the competence of nurses and AYUSH physicians to provide medical abortion and the safety and efficacy of medical abortion services provided by them, we asked those who were aware of medical abortion whether they believed that nurses and AYUSH physicians would be able to correctly assess the length of pregnancy and whether an abortion was complete. Table 2 shows that certified abortion providers were less likely than any other group of providers to state that medical abortion provided by nurses and AYUSH physicians would be safe and effective; indeed, only 58% and 23% of certified providers in Bihar, and 37% and 20% in Maharashtra, expressed confidence about the ability of nurses and AYUSH physicians, respectively, to provide safe and effective medical abortion services. In contrast, over 90% of nurses and AYUSH physicians in Bihar thought nurses would be able to provide safe and effective medical abortion services. Only a few certified abortion providers in Bihar and Maharashtra, 11% and 7%, respectively, thought that nurses would be able to assess gestational age and abortion completion status accurately. Five per cent from both states expressed similar views about AYUSH physicians. Less qualified providers were more likely to express views that nurses would be able to provide safe and effective medical abortion. It is also notable that
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the nurses in both the states were found to be more confident than AYUSH providers about their own ability to provide safe and effective medical abortion services. While providers’ views about non-physicians providing medical abortion safely and effectively were similar in the two states, providers in Bihar were in general more supportive of the provision of medical abortion by nurses and AYUSH physicians than those in Maharashtra. In the in-depth interviews, some physicians expressed concerns about the provision of medical abortion by nurses and AYUSH physicians, notably that these providers would not be able to handle complications, should they occur, and others appeared judgemental about the skills and competence of non-physicians. Some physicians thought being unable to do ultrasounds disqualified them, but they were not aware that WHO says ultrasound is not routinely required.3
“AYUSH doctors should not provide abortion services because they cannot perform ultrasonography.” (Female, Ob/Gyn, urban Maharashtra) “No, they [nurses and AYUSH] should not be allowed to perform medical abortion because they cannot deal with the complications. They can counsel women about how to take MA pills but in case of bleeding, they cannot perform surgical abortion. Only MBBS doctors trained and certified… should be allowed. It is more important to train MBBS doctors first.” (Female, Ob/Gyn, urban Bihar) Others spoke in favour of the provision of abortions by nurses and AYUSH physicians as long as they were trained, could gain experience by working alongside trained and certified abortion providers and had access to back-up facilities. Some even thought that auxiliary nurse-midwives, rural medical practitioners and dais should be allowed 41
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too. As in the survey, it was mostly non-physicians who expressed these views. “First ANMs should be permitted, and then AYUSH doctors should also be given permission… They could also be very useful in restricting wrong practices in abortion services. Training is very important for AYUSH doctors because they do not get any training. If AYUSH doctors can be trained in an emergency, if the ANM is not available in the village, an AYUSH doctor can provide abortion services.” (Male nurse, urban, Bihar) “Yes, they [nurses and AYUSH physicians] should be permitted to provide medical abortion. Nurses have knowledge about it; they should also be permitted. Ayurveds and Homeopaths should also be permitted. Training should be provided to these providers. But Dais should not be permitted.” (Male, Homeopath, rural Bihar) “Nurses, Dais, Homoeopaths and Ayurved doctors should all be trained to provide medical abortion. One way or the other, many are already providing abortion services but are doing so clandestinely. If they get training, they would have the right knowledge to deal with abortion using appropriate techniques. It will decrease the mortality rate.” (Male, Rural medical practitioner, rural Bihar)
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Acceptability of medical abortion Providers were asked about their opinion on the acceptability, to women, of medical abortion services provided by nurses and AYUSH physicians. Findings, presented in Table 3, reveal that only a few certified providers but a larger number of other providers – more from Bihar than Maharashtra – thought that women would indeed like to go to a nurse or AYUSH physician for medical abortion. For example, only 11% of certified providers compared to 25%–38% of other providers from Bihar agreed that medical abortions provided by nurses would be acceptable to women. These results should be interpreted with caution as a large number of providers, e.g. 41%–56% of providers from different categories in Bihar, did not clearly agree or disagree that women seeking abortion would find provision of medical abortion by nurses acceptable. A divide was also observed between allopathic physicians – both certified and non-certified – and other providers with regard to whether expanding the abortion provider base to include nurses and AYUSH physicians would be beneficial for rural women (Table 4). For example, about one in five certified providers and 29%−46% of non-certified allopathic providers in the two states believed that rural women would benefit from an expansion of the provider base; in contrast, 63%−83%
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of other non-physician providers from these states believed that medical abortion services by nurses would be beneficial for rural women. Perceptions were largely similar in both states, although more non-physician providers from Bihar than Maharashtra agreed that expansion of the medical abortion provider base to include nurses and AYUSH would be beneficial for rural women. Again, during in-depth interviews it was mostly the non-physician providers who expressed this view. “If nurses and AYUSH are given permission [to provide medical abortion] and training, women will be able to access services easily in their village or nearby villages and thus women can be prevented from undergoing unsafe abortion.” (Female ANM, rural Maharashtra) “Cases cannot be handled only through MBBS physicians. RMPs, Ayurved physicians, Homeopaths and nurses should be brought in. If it can’t be done, you will not be able to solve this problem of unsafe abortions and people will have to suffer. If they can be trained, it will be for the betterment of society.” (Male, RMP, rural Bihar)
Discussion Studies in India have shown that provision of medical abortion services by nurses and Ayurved physicians is equally safe, effective and acceptable
to women as provided by certified MBBS physicians,9 but there is little evidence about whether such provision is acceptable to a range of providers, from trained physicians to nurses and AYUSH physicians themselves. This paper contributes to this unexplored dimension. Our findings raise four key issues. First, the majority of providers, irrespective of type, spontaneously made three key recommendations for expanding abortion services, namely, to increase the number of trained providers, increase the number of facilities equipped to conduct abortion, and raise awareness among women about the availability and location of abortion services. The option of expansion of the provider base to include nurses and AYUSH physicians was suggested far less often; certified providers in particular were unlikely to support such task-shifting. Those who supported this shift were mostly nonphysicians themselves. Second, allopathic providers (i.e. Ob/Gyns and non-certified physicians with at least an MBBS degree) were not, in large part, supportive of expanding the medical abortion provider base to include nurses and AYUSH physicians. They cited concerns about the ability of these providers to conduct medical abortion safely and effectively, to correctly assess gestational age and abortion completion status, and to handle complications, and even the need for ultrasound, to justify their opposition. Opposition from physicians has also 43
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been seen in other countries, e.g. the United States and China, where it was substantial. However, although they started with scepticism about the ability of the mid-level providers to provide safe abortion services, their opposition in both countries slowly waned over time when their concerns were shown to be groundless.21–23 In India, even if the ground realities are different, FOGSI has consistently supported the government’s efforts to include nurses and AYUSH physicians in the abortion provider base. However, notwithstanding these efforts, our findings point to considerable resistance among Ob/Gyns to task shifting for abortion provision. Although not spoken about enough in this study, professional protectionism and fear of losing income could be two underlying reasons for this resistance. It is thus important that greater efforts are made by all stakeholders to allay these fears and reduce such resistance. Third, in both states, most nurses and somewhat fewer AYUSH physicians were confident about their ability to assess gestational age and abortion completion status and provide medical abortion services safely and effectively. This finding coincides with the findings of another study in India11 and lends support to the view that these providers, who are available in large numbers in rural and inaccessible areas, can and should be trained to provide medical abortion services. Fourth, the views of providers varied widely by setting. Our findings show that providers in Bihar were far more positive than those from Maharashtra about non-physician providers managing medical abortions, including their technical ability, their acceptability to women, and the benefits of an expansion of services for rural women. These differences were possibly due to the fact that the gap between the demand for and supply of safe abortion services is so much greater in Bihar than in Maharashtra, and because in Bihar, doctors are more scarce in many rural health centres, thus necessitating that nurses perform tasks typically reserved for physicians. As a result, not only are nurses in Bihar more confident about their abilities than in Maharashtra, but this situation may also explain why services provided by nurses are more likely to be acceptable to women in Bihar than in Maharashtra.
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Indeed, providers such as auxiliary nurse-midwives are already providing abortion services to lowincome women without training.13,14 These findings have clear programmatic implications. Task shifting of medical abortion provision to nurses and AYUSH physicians is safe, effective and acceptable to women. This study finds that it is also acceptable to and welcomed by most of these providers themselves. A South Asia regional consultation and national consultations held in Bangladesh, India, Nepal and Pakistan that endorsed task shifting did recommend that countries engage nurses and other providers (e.g. AYUSH in India) to the extent possible under existing laws and prepare them for possible changes in the law allowing them to provide abortion services.24 At the same time, a conducive environment, including among physicians, is needed for these new providers to be trained and provide services. For that to happen, it is important that both the government and professional bodies of certified providers (e.g. FOGSI) make efforts to reduce the resistance to change from existing providers. One plausible way of doing this is to involve existing certified providers in the process of task shifting, by engaging them in the training of new providers. Task shifting, if allowed, may turn out to be a huge challenge in terms of both funds and infrastructure. Allocating greater resources for training, supervision and monitoring of abortion service provision by the new cadres of providers and making adequate preparations for the roll-out of service provision by these new providers (e.g. making appropriate back-up facilities ready), should be a focus of the current government strategy, while redoubling efforts to get the amendment passed as soon as possible. Acknowledgements The authors acknowledge the technical and financial support from HRP (UNDP/UNFPA/UNICEF/WHO/ World Bank Special Programme of Research, Development and Research Training in Human Reproduction). The authors would like to thank Shireen Jejeebhoy, Sushanta Kumar Banerjee and Kurus Coyaji for insightful comments on earlier versions of this paper.
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References 1. Banerjee SK, Tank J. Expanding the provider base: improving access, saving lives. In: Hathtootuwa R, Tank J, editors. Prevention of Unsafe Abortion in Asia Oceanic Region. Quezon City, Philippines: Asia and Oceania Federation of Obstetrics and Gynaecology, 2009. p.93–104. 2. Registrar General, India. Maternal mortality in India: 1997–2003. Trends, causes and risk factors. Sample Registration System. New Delhi: Registrar General, India in collaboration with Centre for Global Health Research, University of Toronto, 2006. 3. World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: WHO, 2012. 4. World Health Organization. Task Shifting: Rational redistribution of tasks among health workforce teams: Global recommendations and guidelines. Geneva: WHO, 2008. 5. Warriner IK, Meirik O, Hoffman M, et al. Complication rates of first trimester manual vacuum aspiration abortion performed by physicians and midlevel providers (MLPs) in South Africa and Viet Nam: a randomized, controlled, equivalence trial. Lancet 2006;368(9551):1965–72. 6. Warriner IK, Wang D, Huong NT, et al. Can midlevel health care providers administer medical abortion as safely and effectively as doctors – a randomized, controlled equivalence trial in Nepal. Lancet 2011;377(9772):1155–61. 7. Ipas, IHCAR. Deciding women’s lives are worth saving: Expanding the role of midlevel providers in safe abortion care. Chapel Hill, NC: Ipas, 2002. 8. Berer M. Provision of abortion by mid-level providers: International policy, practice and perspectives. Bulletin of World Health Organization 2009;87:58–63. 9. Jeejebhoy SJ, Kalyanwala S, Mundle S, et al. Feasibility of expanding the medication abortion provider base in India to include ayurvedic physicians and nurses. International Perspectives on Sexual and Reproductive Health 2012;38(3):133–42. 10. Jeejebhoy SJ, Kalyanwala S, Zavier AJF, et al. Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India. Contraception 2011;84:615–21. 11. Patel L, Bennett TA, Halpern CT, et al. Support for provision of early medical abortion by mid-level providers in Bihar and Jharkhand. India. Reproductive Health Matters 2009;17(33):70–79.
12. Ramachandar L, Pelto PJ. Abortion provider and safety of abortion: a community-based study in a rural district of Tamil Nadu, India. Reproductive Health Matters 2004;12(24 Suppl):138–46. 13. Duggal R. The political economy of abortion in India: cost and expenditure patterns. Reproductive Health Matters 2004;12(24 Suppl):130–37. 14. Elul B, Barge S, Verma S, et al. Unwanted Pregnancy and Induced Abortion: Data from Men and Women in Rajasthan, India. New Delhi: Population Council, 2004. 15. Central Bureau of Health Intelligence. National Health Profile 2012. New Delhi: MOHFW, Government of India, 2013. 16. Elul B, Sheriar N, Anand A, et al. Are obstetriciangynaecologists in India aware of and providing medical abortion? Journal of Obstetrics and Gynaecology of India 2006;56(4):340–45. 17. Ganatra B, Manning N, Suranjeen PP. Medical abortion in Bihar and Jharkhand: a study of service providers, chemists, women and men. New Delhi: Ipas, 2005. 18. International Institute for Population Sciences, Macro International. National Family Health Survey (NFHS-3), 2005–06: India, Vol. I. Mumbai: IIPS, 2007. 19. Ministry of Health and Family Welfare. Family Welfare Statistics in India – 2009–10. New Delhi: MOHFW, Government of India, 2011. 20. Acharya R, Kalyanwala S. Knowledge, attitudes, and practices of certified providers of medical abortion: Evidence from Bihar and Maharashtra, India. International Journal of Gynecology and Obstetrics 2012;118(Suppl):S40–46. 21. Chong YS, Mattar CN. Mid-level providers: a safe solution for unsafe abortion. Lancet 2006;368:1939–40. 22. Kaiser Family Foundation. Two national surveys: views of Americans and health care providers on medical abortion: what they know, what they think they know and what they want. Menlo Park, CA: Henry J Kaiser Family Foundation, 1998. 23. Advocating for nurse practitioners, nurse-midwives and physician assistants as abortion providers. Policy statements adopted by the Governing Council of the American Public Health Association. Washington, DC: APHA, 1999. 24. Population Council. Expanding access to safe abortion and post-abortion care: Recommendations of a South Asia Regional Consultation, 2011. New Delhi: Population Council, 2011.
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Résumé Il est difficile de dire si les prestataires de santé agréés ou non en Inde soutiennent la réforme de la loi sur l’interruption médicale de grossesse qui devrait élargir la base des prestataires de services d’avortement pour permettre aux infirmières qualifiées et aux médecins AYUSH (qui sont formés au système indien de médecine) de pratiquer les avortements médicamenteux. Pour étudier leurs idées, nous avons réalisé une enquête auprès de 1200 médecins et autres prestataires de soins de santé dans les États du Maharashtra et Bihar et des entretiens approfondis avec 34 d’entre eux qui avaient eu recours à l’avortement médicamenteux dans leur pratique. Les conclusions indiquent que les gynécologues-obstétriciens et autres médecins allopathiques étaient moins favorables que les non-médecins à la possibilité pour les infirmières et les médecins AYUSH de réaliser des avortements médicamenteux précoces. Les médecins ne pensaient pas que ces personnels pouvaient évaluer correctement les conditions à remplir pour bénéficier d’un avortement médicamenteux. Au contraire, la majorité des non-médecins trouvaient acceptable le transfert de l’avortement médicamenteux aux infirmières qualifiées et aux médecins AYUSH, et ils pensaient que ces prestataires pourraient pratiquer l’avortement médicamenteux aussi sûrement et efficacement que les médecins qualifiés. Si les réformes sont adoptées, les pouvoirs publics devront s’efforcer de former les nouveaux prestataires à ce rôle, préparer l’infrastructure de santé pour les y inclure et créer, notamment parmi les médecins, un environnement qui soit propice à la réalisation d’avortements médicamenteux par des non-médecins.
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Resumen Existe limitada evidencia en cuanto a si profesionales de la salud certificados y no certificados en India apoyan la reforma de la ley de Interrupción Médica del Embarazo para ampliar la base de prestadores de servicios de aborto con el fin de permitir que enfermeras capacitadas y médicos de AYUSH (capacitados en sistemas indios de medicina) proporcionen servicios de aborto con medicamentos. Para explorar sus puntos de vista, encuestamos a 1200 médicos y otros profesionales de la salud en los estados de Maharashtra y Bihar y realizamos entrevistas a profundidad con 34 de ellos que habían utilizado el método de aborto con medicamentos en sus consultorios. Los hallazgos indican que los gineco-obstetras y otros médicos alópatas se mostraron más renuentes que profesionales no médicos para apoyar la prestación de servicios de aborto con medicamentos en las etapas iniciales del embarazo por parte de enfermeras y médicos de AYUSH. Los médicos no creían que estos profesionales de la salud podrían evaluar correctamente la elegibilidad de las mujeres para tener un aborto con medicamentos. En cambio, la mayoría de los profesionales no médicos consideraron aceptable asignar a enfermeras y médicos de AYUSH capacitados la tarea de proporcionar servicios de aborto con medicamentos, y confiaban en que estos profesionales de la salud podrían proporcionar dichos servicios tan segura y eficazmente como los médicos capacitados. Suponiendo que las reformas sean aprobadas, el gobierno y las asociaciones de profesionales médicos deberán realizar esfuerzos para capacitar a estos nuevos prestadores de servicios para que asuman este rol, preparar la infraestructura de salud para incluirlos y crear un ambiente, incluso entre médicos, que se preste para permitir que profesionales no médicos proporcionen servicios de aborto con medicamentos.
Physicians’ and non-physicians’ views about provision of medical abortion by nurses and AYUSH physicians in Maharashtra and Bihar, India Rajib Acharya,a Shveta Kalyanwalab a Associate, Population Council, New Delhi, India. Correspondence: [email protected] b Independent consultant, New Delhi, India
Abstract: There is only limited evidence on whether certified and uncertified health care providers in India support reforming the Medical Termination of Pregnancy (MTP) Act to expand the abortion provider base to allow trained nurses and AYUSH physicians (who are trained in Indian systems of medicine) to provide medical abortion. To explore their views, we conducted a survey of 1,200 physicians and other health care providers in Maharashtra and Bihar states and in-depth interviews with 34 of them who had used medical abortion in their practices. Findings indicate that obstetrician-gynaecologists and other allopathic physicians were less supportive than non-physicians of nurses and AYUSH physicians providing early medical abortion. The physicians did not think that these providers would be able to assess women’s eligibility for medical abortion correctly. In contrast, the majority of non-physicians found task shifting of medical abortion provision to trained nurses and AYUSH physicians acceptable, and they were confident that these providers would be able to provide medical abortion as safely and effectively as trained physicians. Assuming the reforms are passed, efforts will need to be made by government and medical professional bodies to train these new providers to undertake this role, prepare the health infrastructure to include them, and create an environment, including among physicians, that is conducive to enabling non-physicians to provide medical abortion. © 2015 Reproductive Health Matters Keywords: abortion law and policy, medical abortion, task shifting, mid-level providers, AYUSH physicians, nurses, India While abortion has been legal in India since the enactment of the Medical Termination of Pregnancy (MTP) Act of 1971 and medical abortion (MA) has been approved since 2002,* women in
India continue to have abortions outside of registered settings and/or from uncertified providers mainly because:
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availability of legal abortion services is concentrated in and around urban areas, even though more than 70% of the population live in rural areas, where demand for abortion is high; there is an acute shortage of trained providers, heightened by government policy of restricting provision to trained physicians (Ob/Gyns and general physicians); and even though mandated in government policy, most of the public primary care facilities are not equipped to provide abortion services because of lack of trained providers and lack of availability of equipment and medical abortion pills.
*Abortion is legal in India when performed by a certified medical practitioner in a hospital or institution approved by the Government. Obstetrician-gynaecologists (Ob/Gyns) are certified by way of their training. Other doctors with a degree equivalent to MBBS or higher can provide abortions up to 12 weeks of pregnancy LMP if they have received theoretical and practical training involving observing, assisting and performing a total of 25 abortions in a registered facility. Only Ob/Gyns can provide abortions of pregnancies between 13–20 weeks. Certified medical practitioners can also prescribe medical abortion pills up to nine weeks of pregnancy in an unapproved clinic, provided they have referral access to a facility approved for abortions.
In rural and inaccessible areas, where access to approved services and trained physicians is
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Doi: 10.1016/S0968-8080(14)43787-X
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limited, informal/untrained providers are the most accessible source of abortion services,1 and abortionrelated morbidity remains high. While the current incidence of abortion-related complications in India is not known, the latest available estimates, for 2001–03, suggested that complications arising from unsafe abortion accounted for some 8% of maternal deaths in the country.2 To reduce maternal mortality due to unsafe abortion, the World Health Organization has recommended task shifting to increase the cadre and number of personnel, including non-physicians such as nurses and nurse-midwives, who are trained and equipped to provide abortion services at the primary care level.3 Evidence from both low- and high-income countries shows that task-shifting from physicians to other health professionals – including nurses, nurse-midwives and other non-physicians, as well as physicians trained in Indian Systems of Medicine – has been a successful model for expanding abortion services without compromising patient safety and satisfaction,4–10 and that women are supportive of and satisfied with the provision of abortion services by these providers. Moreover, non-physicians are generally more likely than trained physicians to work in remote and under-served areas of India, in close proximity to the community, and to offer more affordable services.7,11 In fact, many of these uncertified providers do provide both surgical and medical abortion in response to demand from the community.12–14 Thus, formally expanding the range of medical abortion providers in India is both a safe and feasible option. India has a large work force of non-physician providers and AYUSH physicians* who can be trained and certified to provide abortion services. In 2011, India had 628,634 registered AYUSH physicians and 1,406,006 trained nurses.15 Recognising the potential for expanding the abortion provider base through this large number of providers, a government-appointed expert committee, comprised of academics, policy makers, members of the Federation of Obstetric and Gynaecological Societies of India (FOGSI) and other stakeholders, recommended amendments *AYUSH encompasses physicians trained in Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy. A separate Department of AYUSH has been set up in the Ministry of Health and Family Welfare, Government of India, for the provision of services relating to these officially recognized Indian Systems of Medicine.
to the existing MTP laws in 2009 to include nurses and AYUSH physicians to be trained to provide abortion services and certified by approved training centres. The amendments are under active consideration by the Ministry of Health and Family Welfare at this writing. In spite of government interest in task-shifting of abortion services to non-physician providers, however, there is little evidence either of the extent of these providers’ own interest in providing medical abortion or the perspectives of Ob/Gyns and other physicians on training these cadres as abortion providers. The few studies in India on these questions, published between 2005 and 2009, found that trained physicians typically opposed the expansion of the provider base to include non-physicians.16,17 One study found that only 40% of 413 Ob/Gyns interviewed believed that non-physician providers could be trained to provide medical abortion.16 A facility-based study published in 2009 found that only 34% of 54 Ob/Gyns and 58% of 88 general physicians interviewed were supportive of non-physicians’ participation in the provision of early medical abortion; in contrast, however, 74% of 263 nonphysicians interviewed expressed interest in being trained themselves to provide medical abortion.11 Given the continuing unmet need for more trained abortion providers and the upcoming amendment to the law, it is important to find out what the views of Ob/Gyns and other physicians, as well as a range of non-physician health care providers are, as regards expanding the provider base. This information may help the government and other stakeholders plan a strategy to work with trained physicians in order to create an environment, including among physicians, conducive to smooth implementation of the amended law. The objective of this paper is to shed light on the views of a range of health care providers on the provision of medical abortion by nurses and AYUSH physicians. Study setting The study was conducted from November 2009 to May 2010 in four selected districts in the state of Maharashtra, a more developed state with better health infrastructure than the national average, and four districts in the state of Bihar, a relatively poorly developed state with a poor health infrastructure. The two states were selected because they vary in socioeconomic and demographic characteristics and sexual and reproductive health 37
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indicators and represent two contrasting scenarios in the country, and their total population size is not very different. Thus, for example, the percentage of women of reproductive age who were literate in Maharashtra (76%) was twice that observed in Bihar (38%); similar differences, respectively, were found in contraceptive prevalence (67% vs. 34%) and unmet need for contraception (10% vs 23%).18 As regards abortion, government statistics from 2009–2010 show that about 86,339 abortions were conducted in registered facilities in Maharashtra and 19,509 in registered facilities in Bihar. Statistics on unregistered abortions are not available by state. However, in Bihar there are only 146 approved facilities for abortion services compared to 2,846 in Maharashtra, which goes a long way to explaining why these numbers are so different between the two states.19 Design and methodology Data for this paper come from a larger descriptive study focusing on the perspectives and experiences of a wide range of providers in rural and urban areas in both states with regard to medical abortion. The study focused on five categories of providers: Ob/Gyns, general physicians (irrespective of whether they were certified to provide abortions), nurses and auxiliary nurse-midwives (ANMs), AYUSH physicians, informal providers (including rural medical practitioners, or RMPs*) and traditional birth attendants (dais). It included both a survey using a structured questionnaire and in-depth interviews and was conducted in four districts of each state. The districts were selected to be representative of different regions of each state. A detailed description of the sampling process can be found in another article, with data from the same study, on certified providers’ knowledge, attitudes and practices of medical abortion.20 Those who consented to participate (response rate 89−92% for the different categories of providers) were interviewed using a questionnaire that employed structured, closed-ended questions, presented with their answers below. This paper focuses on the survey data drawn from a total of 1,200 health care providers, consisting of 270 certified abortion providers (240 Ob/Gyns and 30 general physicians), 210 *Rural medical practitioners usually learn their skills in the course of assisting trained medical doctors.
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uncertified allopathic physicians with MBBS/ MS/MD degrees, and 240 each of AYUSH providers, nurses/auxiliary nurse-midwives, and informal providers (RMPs and dais). It also draws on data from in-depth interviews with 34 providers: 19 from Bihar and 15 from Maharashtra. Respondents (36) for in-depth interviews were selected randomly from providers who responded to the survey and reported that they had used medical abortion in their practice.
Findings Characteristics of providers The median age of respondents was 41 years (range 19–81), with physicians somewhat older than non-physicians (43 vs. 38 years). Among physicians certified to provide abortion, 37% had a post-graduate degree in medicine or surgery and 52% had a post-graduate Diploma in Gynaecology and Obstetrics. Among non-certified allopathic physicians, 70% had an MBBS degree and the rest had a post-graduate degree in medicine or surgery. The sample covered 83 (35%) Ayurved, 151 (63%) homeopaths, and 6 Unani physicians with Bachelor of Ayurveda, Medicine and Surgery, Bachelor of Homeopathic Medicine and Surgery and Bachelor of Unani Medical Science degrees, respectively. The survey also covered 85 nurses with a degree or diploma in nursing and 155 auxiliary nurse-midwives (ANMs) with 12 years of schooling on average. RMPs and dais were slightly less educated than ANMs – on average they had completed ten years of schooling. The general awareness of medical abortion (that is, awareness that abortion can be induced using a combination of mifepristone and misoprostol) was universal among the certified abortion providers, and among 77% of non-certified allopathic providers and 59% of nurses and ANMs. Awareness of medical abortion was far more limited among AYUSH physicians and informal providers – 47% and 26%, respectively. Expansion of abortion services All providers, irrespective of whether they had ever provided abortion services, were asked to suggest ways in which access to abortion services could be expanded. The question was openended and providers’ spontaneous responses were recorded. Table 1 shows the various suggestions; key among these were increasing the number of trained providers (MBBS physicians
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and Ob/Gyns − 23%−48% in Bihar and 63%−86% in Maharashtra), increasing the number of registered facilities in which abortions may be conducted (37%−65% in Bihar and 32%−60% in Maharashtra) and expanding community awareness about the location of abortion services (33%−52% in Bihar and 34%−44% in Maharashtra). Physicians were somewhat more likely than non-physicians to make each of these three suggestions for ways of expanding services. During the in-depth interviews, providers reiterated the view that training the cadres of providers permitted under the current law (MBBS and Ob/Gyn) was an effective way of expanding services. “In my opinion… we are falling very short of the required numbers of trained providers. We have to increase the number of specialists. All MBBS trained doctors should be given special compulsory
training in abortion techniques and all medicos joining the health services should be compulsorily posted in rural areas. This will make it possible to provide abortion services at village level.” (Male, certified MBBS physician, rural Maharashtra) “There is a need for special training to make these [abortion] services better.… The number of service providers as well as government facilities should be increased. ” (Male, Ayurved physician, rural Bihar) “For this, training must be provided to the doctors nearby and to those who are good and educated, and not to [rural medical practitioners]. They do not have any knowledge. Training needs to be given on the correct treatment to be given to a woman who comes to a provider bleeding.” (Female, ANM, rural Bihar) 39
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Several respondents also suggested that women should be given information on the availability and location of safe abortion services. “There are a lot of women who don’t know about [medical abortion] pills. They wait for three or more months. If this information could be spread among women in villages through mass communication then they may come directly to us and ask for medical abortion. Women should be told to contact only a trained person instead of going here and there, or to a medical store or a nurse.” (Female, Ob/Gyn, urban Bihar) “While there should be proper training [of providers] there should also be advertisements through the electronic media, that tell people what is harmful and appeal to women to take tablets only from well-trained doctors.” (Female, Ob/Gyn, rural Maharashtra) “Health committees in villages should be more actively engaged in providing mass education about these matters. As it is, government-sponsored health education campaigns do emphasize that ‘The shorter the duration of the pregnancy, the safer the abortion’. But I do not think people take this message seriously. They wait till the pregnancy is 15–20 weeks and then come requesting an abortion! This tendency needs to be changed immediately so that more abortions can be done safely.” (Male, Certified MBBS physician, rural Maharashtra) Fewer physicians than non-physicians (11%–24% vs. 8%–35% in Bihar and 4%–14% vs. 7%–28% in Maharashtra, respectively) suggested allowing non-physician providers to provide surgical and/or medical abortion in both the survey and in-depth interviews. “Training should be given to all working in the health sector. Homeopath and Ayurved doctors also should be given training so that abortion services can be available at village level. Homeopath and Ayurved doctors do go to rural areas and if training is given to them, women from villages would benefit… ” (Female, ANM, rural Maharashtra) “It would be beneficial to give training to nurses and homeopathic doctors because there are subcentres where only nurses are appointed… Training should be given to each nurse appointed at sub-centres so that women in the village can avail of services without spending money on travelling.” (Female ANM, rural Maharashtra) 40
“Emphasis should be given to educate nurses or other providers so that they can be ready to handle the complications [of abortion]. They should be trained to perform surgical abortion also so that they could provide surgical services smoothly.” (Female, Ob/Gyn, rural Bihar) With a few notable differences, providers from Bihar and Maharashtra tended to make similar suggestions for expanding services. Providers from Maharashtra were far more likely than providers from Bihar to suggest increasing the number of trained providers and abortion facilities; the only exceptions were Ob/Gyns from Bihar, who were more likely than their counterparts in Maharashtra to suggest increasing the number of facilities providing abortion services (65% vs. 50%). Physicians from Bihar were more likely than their counterparts from Maharashtra to suggest allowing non-physicians to provide surgical or medical abortion – 11% vs. 7% and 24% vs. 14%, respectively. Safety and efficacy of medical abortion In order to understand the views of providers about the competence of nurses and AYUSH physicians to provide medical abortion and the safety and efficacy of medical abortion services provided by them, we asked those who were aware of medical abortion whether they believed that nurses and AYUSH physicians would be able to correctly assess the length of pregnancy and whether an abortion was complete. Table 2 shows that certified abortion providers were less likely than any other group of providers to state that medical abortion provided by nurses and AYUSH physicians would be safe and effective; indeed, only 58% and 23% of certified providers in Bihar, and 37% and 20% in Maharashtra, expressed confidence about the ability of nurses and AYUSH physicians, respectively, to provide safe and effective medical abortion services. In contrast, over 90% of nurses and AYUSH physicians in Bihar thought nurses would be able to provide safe and effective medical abortion services. Only a few certified abortion providers in Bihar and Maharashtra, 11% and 7%, respectively, thought that nurses would be able to assess gestational age and abortion completion status accurately. Five per cent from both states expressed similar views about AYUSH physicians. Less qualified providers were more likely to express views that nurses would be able to provide safe and effective medical abortion. It is also notable that
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the nurses in both the states were found to be more confident than AYUSH providers about their own ability to provide safe and effective medical abortion services. While providers’ views about non-physicians providing medical abortion safely and effectively were similar in the two states, providers in Bihar were in general more supportive of the provision of medical abortion by nurses and AYUSH physicians than those in Maharashtra. In the in-depth interviews, some physicians expressed concerns about the provision of medical abortion by nurses and AYUSH physicians, notably that these providers would not be able to handle complications, should they occur, and others appeared judgemental about the skills and competence of non-physicians. Some physicians thought being unable to do ultrasounds disqualified them, but they were not aware that WHO says ultrasound is not routinely required.3
“AYUSH doctors should not provide abortion services because they cannot perform ultrasonography.” (Female, Ob/Gyn, urban Maharashtra) “No, they [nurses and AYUSH] should not be allowed to perform medical abortion because they cannot deal with the complications. They can counsel women about how to take MA pills but in case of bleeding, they cannot perform surgical abortion. Only MBBS doctors trained and certified… should be allowed. It is more important to train MBBS doctors first.” (Female, Ob/Gyn, urban Bihar) Others spoke in favour of the provision of abortions by nurses and AYUSH physicians as long as they were trained, could gain experience by working alongside trained and certified abortion providers and had access to back-up facilities. Some even thought that auxiliary nurse-midwives, rural medical practitioners and dais should be allowed 41
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too. As in the survey, it was mostly non-physicians who expressed these views. “First ANMs should be permitted, and then AYUSH doctors should also be given permission… They could also be very useful in restricting wrong practices in abortion services. Training is very important for AYUSH doctors because they do not get any training. If AYUSH doctors can be trained in an emergency, if the ANM is not available in the village, an AYUSH doctor can provide abortion services.” (Male nurse, urban, Bihar) “Yes, they [nurses and AYUSH physicians] should be permitted to provide medical abortion. Nurses have knowledge about it; they should also be permitted. Ayurveds and Homeopaths should also be permitted. Training should be provided to these providers. But Dais should not be permitted.” (Male, Homeopath, rural Bihar) “Nurses, Dais, Homoeopaths and Ayurved doctors should all be trained to provide medical abortion. One way or the other, many are already providing abortion services but are doing so clandestinely. If they get training, they would have the right knowledge to deal with abortion using appropriate techniques. It will decrease the mortality rate.” (Male, Rural medical practitioner, rural Bihar)
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Acceptability of medical abortion Providers were asked about their opinion on the acceptability, to women, of medical abortion services provided by nurses and AYUSH physicians. Findings, presented in Table 3, reveal that only a few certified providers but a larger number of other providers – more from Bihar than Maharashtra – thought that women would indeed like to go to a nurse or AYUSH physician for medical abortion. For example, only 11% of certified providers compared to 25%–38% of other providers from Bihar agreed that medical abortions provided by nurses would be acceptable to women. These results should be interpreted with caution as a large number of providers, e.g. 41%–56% of providers from different categories in Bihar, did not clearly agree or disagree that women seeking abortion would find provision of medical abortion by nurses acceptable. A divide was also observed between allopathic physicians – both certified and non-certified – and other providers with regard to whether expanding the abortion provider base to include nurses and AYUSH physicians would be beneficial for rural women (Table 4). For example, about one in five certified providers and 29%−46% of non-certified allopathic providers in the two states believed that rural women would benefit from an expansion of the provider base; in contrast, 63%−83%
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of other non-physician providers from these states believed that medical abortion services by nurses would be beneficial for rural women. Perceptions were largely similar in both states, although more non-physician providers from Bihar than Maharashtra agreed that expansion of the medical abortion provider base to include nurses and AYUSH would be beneficial for rural women. Again, during in-depth interviews it was mostly the non-physician providers who expressed this view. “If nurses and AYUSH are given permission [to provide medical abortion] and training, women will be able to access services easily in their village or nearby villages and thus women can be prevented from undergoing unsafe abortion.” (Female ANM, rural Maharashtra) “Cases cannot be handled only through MBBS physicians. RMPs, Ayurved physicians, Homeopaths and nurses should be brought in. If it can’t be done, you will not be able to solve this problem of unsafe abortions and people will have to suffer. If they can be trained, it will be for the betterment of society.” (Male, RMP, rural Bihar)
Discussion Studies in India have shown that provision of medical abortion services by nurses and Ayurved physicians is equally safe, effective and acceptable
to women as provided by certified MBBS physicians,9 but there is little evidence about whether such provision is acceptable to a range of providers, from trained physicians to nurses and AYUSH physicians themselves. This paper contributes to this unexplored dimension. Our findings raise four key issues. First, the majority of providers, irrespective of type, spontaneously made three key recommendations for expanding abortion services, namely, to increase the number of trained providers, increase the number of facilities equipped to conduct abortion, and raise awareness among women about the availability and location of abortion services. The option of expansion of the provider base to include nurses and AYUSH physicians was suggested far less often; certified providers in particular were unlikely to support such task-shifting. Those who supported this shift were mostly nonphysicians themselves. Second, allopathic providers (i.e. Ob/Gyns and non-certified physicians with at least an MBBS degree) were not, in large part, supportive of expanding the medical abortion provider base to include nurses and AYUSH physicians. They cited concerns about the ability of these providers to conduct medical abortion safely and effectively, to correctly assess gestational age and abortion completion status, and to handle complications, and even the need for ultrasound, to justify their opposition. Opposition from physicians has also 43
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been seen in other countries, e.g. the United States and China, where it was substantial. However, although they started with scepticism about the ability of the mid-level providers to provide safe abortion services, their opposition in both countries slowly waned over time when their concerns were shown to be groundless.21–23 In India, even if the ground realities are different, FOGSI has consistently supported the government’s efforts to include nurses and AYUSH physicians in the abortion provider base. However, notwithstanding these efforts, our findings point to considerable resistance among Ob/Gyns to task shifting for abortion provision. Although not spoken about enough in this study, professional protectionism and fear of losing income could be two underlying reasons for this resistance. It is thus important that greater efforts are made by all stakeholders to allay these fears and reduce such resistance. Third, in both states, most nurses and somewhat fewer AYUSH physicians were confident about their ability to assess gestational age and abortion completion status and provide medical abortion services safely and effectively. This finding coincides with the findings of another study in India11 and lends support to the view that these providers, who are available in large numbers in rural and inaccessible areas, can and should be trained to provide medical abortion services. Fourth, the views of providers varied widely by setting. Our findings show that providers in Bihar were far more positive than those from Maharashtra about non-physician providers managing medical abortions, including their technical ability, their acceptability to women, and the benefits of an expansion of services for rural women. These differences were possibly due to the fact that the gap between the demand for and supply of safe abortion services is so much greater in Bihar than in Maharashtra, and because in Bihar, doctors are more scarce in many rural health centres, thus necessitating that nurses perform tasks typically reserved for physicians. As a result, not only are nurses in Bihar more confident about their abilities than in Maharashtra, but this situation may also explain why services provided by nurses are more likely to be acceptable to women in Bihar than in Maharashtra.
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Indeed, providers such as auxiliary nurse-midwives are already providing abortion services to lowincome women without training.13,14 These findings have clear programmatic implications. Task shifting of medical abortion provision to nurses and AYUSH physicians is safe, effective and acceptable to women. This study finds that it is also acceptable to and welcomed by most of these providers themselves. A South Asia regional consultation and national consultations held in Bangladesh, India, Nepal and Pakistan that endorsed task shifting did recommend that countries engage nurses and other providers (e.g. AYUSH in India) to the extent possible under existing laws and prepare them for possible changes in the law allowing them to provide abortion services.24 At the same time, a conducive environment, including among physicians, is needed for these new providers to be trained and provide services. For that to happen, it is important that both the government and professional bodies of certified providers (e.g. FOGSI) make efforts to reduce the resistance to change from existing providers. One plausible way of doing this is to involve existing certified providers in the process of task shifting, by engaging them in the training of new providers. Task shifting, if allowed, may turn out to be a huge challenge in terms of both funds and infrastructure. Allocating greater resources for training, supervision and monitoring of abortion service provision by the new cadres of providers and making adequate preparations for the roll-out of service provision by these new providers (e.g. making appropriate back-up facilities ready), should be a focus of the current government strategy, while redoubling efforts to get the amendment passed as soon as possible. Acknowledgements The authors acknowledge the technical and financial support from HRP (UNDP/UNFPA/UNICEF/WHO/ World Bank Special Programme of Research, Development and Research Training in Human Reproduction). The authors would like to thank Shireen Jejeebhoy, Sushanta Kumar Banerjee and Kurus Coyaji for insightful comments on earlier versions of this paper.
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References 1. Banerjee SK, Tank J. Expanding the provider base: improving access, saving lives. In: Hathtootuwa R, Tank J, editors. Prevention of Unsafe Abortion in Asia Oceanic Region. Quezon City, Philippines: Asia and Oceania Federation of Obstetrics and Gynaecology, 2009. p.93–104. 2. Registrar General, India. Maternal mortality in India: 1997–2003. Trends, causes and risk factors. Sample Registration System. New Delhi: Registrar General, India in collaboration with Centre for Global Health Research, University of Toronto, 2006. 3. World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: WHO, 2012. 4. World Health Organization. Task Shifting: Rational redistribution of tasks among health workforce teams: Global recommendations and guidelines. Geneva: WHO, 2008. 5. Warriner IK, Meirik O, Hoffman M, et al. Complication rates of first trimester manual vacuum aspiration abortion performed by physicians and midlevel providers (MLPs) in South Africa and Viet Nam: a randomized, controlled, equivalence trial. Lancet 2006;368(9551):1965–72. 6. Warriner IK, Wang D, Huong NT, et al. Can midlevel health care providers administer medical abortion as safely and effectively as doctors – a randomized, controlled equivalence trial in Nepal. Lancet 2011;377(9772):1155–61. 7. Ipas, IHCAR. Deciding women’s lives are worth saving: Expanding the role of midlevel providers in safe abortion care. Chapel Hill, NC: Ipas, 2002. 8. Berer M. Provision of abortion by mid-level providers: International policy, practice and perspectives. Bulletin of World Health Organization 2009;87:58–63. 9. Jeejebhoy SJ, Kalyanwala S, Mundle S, et al. Feasibility of expanding the medication abortion provider base in India to include ayurvedic physicians and nurses. International Perspectives on Sexual and Reproductive Health 2012;38(3):133–42. 10. Jeejebhoy SJ, Kalyanwala S, Zavier AJF, et al. Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India. Contraception 2011;84:615–21. 11. Patel L, Bennett TA, Halpern CT, et al. Support for provision of early medical abortion by mid-level providers in Bihar and Jharkhand. India. Reproductive Health Matters 2009;17(33):70–79.
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Résumé Il est difficile de dire si les prestataires de santé agréés ou non en Inde soutiennent la réforme de la loi sur l’interruption médicale de grossesse qui devrait élargir la base des prestataires de services d’avortement pour permettre aux infirmières qualifiées et aux médecins AYUSH (qui sont formés au système indien de médecine) de pratiquer les avortements médicamenteux. Pour étudier leurs idées, nous avons réalisé une enquête auprès de 1200 médecins et autres prestataires de soins de santé dans les États du Maharashtra et Bihar et des entretiens approfondis avec 34 d’entre eux qui avaient eu recours à l’avortement médicamenteux dans leur pratique. Les conclusions indiquent que les gynécologues-obstétriciens et autres médecins allopathiques étaient moins favorables que les non-médecins à la possibilité pour les infirmières et les médecins AYUSH de réaliser des avortements médicamenteux précoces. Les médecins ne pensaient pas que ces personnels pouvaient évaluer correctement les conditions à remplir pour bénéficier d’un avortement médicamenteux. Au contraire, la majorité des non-médecins trouvaient acceptable le transfert de l’avortement médicamenteux aux infirmières qualifiées et aux médecins AYUSH, et ils pensaient que ces prestataires pourraient pratiquer l’avortement médicamenteux aussi sûrement et efficacement que les médecins qualifiés. Si les réformes sont adoptées, les pouvoirs publics devront s’efforcer de former les nouveaux prestataires à ce rôle, préparer l’infrastructure de santé pour les y inclure et créer, notamment parmi les médecins, un environnement qui soit propice à la réalisation d’avortements médicamenteux par des non-médecins.
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Resumen Existe limitada evidencia en cuanto a si profesionales de la salud certificados y no certificados en India apoyan la reforma de la ley de Interrupción Médica del Embarazo para ampliar la base de prestadores de servicios de aborto con el fin de permitir que enfermeras capacitadas y médicos de AYUSH (capacitados en sistemas indios de medicina) proporcionen servicios de aborto con medicamentos. Para explorar sus puntos de vista, encuestamos a 1200 médicos y otros profesionales de la salud en los estados de Maharashtra y Bihar y realizamos entrevistas a profundidad con 34 de ellos que habían utilizado el método de aborto con medicamentos en sus consultorios. Los hallazgos indican que los gineco-obstetras y otros médicos alópatas se mostraron más renuentes que profesionales no médicos para apoyar la prestación de servicios de aborto con medicamentos en las etapas iniciales del embarazo por parte de enfermeras y médicos de AYUSH. Los médicos no creían que estos profesionales de la salud podrían evaluar correctamente la elegibilidad de las mujeres para tener un aborto con medicamentos. En cambio, la mayoría de los profesionales no médicos consideraron aceptable asignar a enfermeras y médicos de AYUSH capacitados la tarea de proporcionar servicios de aborto con medicamentos, y confiaban en que estos profesionales de la salud podrían proporcionar dichos servicios tan segura y eficazmente como los médicos capacitados. Suponiendo que las reformas sean aprobadas, el gobierno y las asociaciones de profesionales médicos deberán realizar esfuerzos para capacitar a estos nuevos prestadores de servicios para que asuman este rol, preparar la infraestructura de salud para incluirlos y crear un ambiente, incluso entre médicos, que se preste para permitir que profesionales no médicos proporcionen servicios de aborto con medicamentos.
