research paper on abortion in india

Volume 20 Supplement 1

Availability of quality-assured medical abortion medicines

• Open access
• Published: 05 June 2024

Landscape assessment of the availability of medical abortion medicines in India

• Priya Karna 1 ,
• K. Aparna Sharma 2 ,
• Amy Grossman 3 ,
• Madhur Gupta 1 ,
• Tapas Chatterjee 1 ,
• Natalie Williams 3 ,
• Ndola Prata 3 , 4 ,
• Annik Sorhaindo 5 ,
• Laurence Läser   ORCID: orcid.org/0009-0009-4841-0870 5 ,
• Ulrika Rehnström Loi 5 ,
• Bela Ganatra 5 &
• Pushpa Chaudhary 1  

Reproductive Health volume  20 , Article number:  193 ( 2023 ) Cite this article

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Metrics details

Medical abortion with mifepristone and misoprostol can be provided up to 63 days’ gestation in India. This accounts for 67.5 percent of all abortions in the country. We conducted an assessment to determine the availability of medical abortion medicines, specifically the combi-pack, in India.

We applied the World Health Organization landscape assessment protocol at the national level. The assessment protocol included a five-step adaptation of an existing availability framework, including online data collection, desk review, country-level key informant interviews, and an analysis to identify barriers and opportunities to improve medical abortion availability. The assessment was conducted between August and March 2021.

Medicines for medical abortion are included in the national essential drug list and available with prescription in India. The assessment identified 42 combi-pack products developed by 35 manufacturers. The quality of medical abortion medicines is regulated by national authorities; but as health is devolved to states, there are significant inter-state variations. This is seen across financing, procurement, manufacturing, and monitoring mechanisms for quality assurance of medical abortion medicines prior to distribution. There is a need to strengthen supply chain systems, ensure consistent availability of trained providers and build community awareness on use of medical abortion medicines for early abortions, at the time of the assessment.

Opportunities to improve availability and quality of medical abortion medicines exist. For example, uniform implementation of regulatory standards, greater emphasis on quality-assurance during manufacturing, and standardizing of procurement and supply chain systems across states. Regular in-service training of providers on medical abortion is required. Finally, innovations in evidence dissemination and community engagement about the recently amended abortion law are needed.

Plain language summary

Medical abortion is popular in India and benefits from a liberal legal context. It is important to understand the availability of quality abortion medicines in the country. Using the World Health Organization country assessment protocol and availability framework for medical abortion medicines we examined the availability of these medicines from supply to demand. We used this information to identify opportunities for increasing availability of quality-assured medical abortion medicines. We found that the context for medical abortion varies across states. Strengthening procurement and supply chain management, with a greater emphasis on quality-assurance and regulation of manufacturing should be instituted at the state-level. Training is also needed to increase provider knowledge of the latest national guidelines and laws to ensure respectful and person-centered services. Finally, the public should be informed about medical abortion as a safe and effective choice, especially for early abortions.

Abortion has been legal in India for nearly five decades, accommodating a broad range of conditions [ 1 ]. Medical abortion (MA) using either a combination of mifepristone followed by misoprostol, or misoprostol alone is a well-accepted, safe, and effective method [ 2 , 3 ]. As per the 2019–2021 National Family Health Survey (NFHS), MA is the predominant method of abortion in India (67.5%) [ 4 ]. Women’s preference for MA is influenced by various factors, like safety and effectiveness, degree of medical intervention, perception of what is natural, perceived pain and adverse effects, time required at the facility, confidentiality, need for multiple clinic visits, associated cost and physical examination requirements [ 5 , 6 ]. Nearly half of women (48%) sought abortion due to unplanned pregnancy [ 6 ]. The World Health Organization (WHO) estimates that nearly 21.5 million or 44 percent of all pregnancies in India are unintended [ 7 ]. The share of unintended pregnancies that end in abortion has nearly doubled from 47 percent in 1990–1994 to 77 percent in 2015–2019 [ 7 , 8 ].

WHO defines unsafe abortion as terminating an unintended pregnancy by unskilled individuals or in substandard medical conditions, or both [ 9 ]. In India, around 55% of abortions are performed by medical doctors, with a significant variation between rural (48%) and urban (66%) areas [ 4 ]. This indicates that rural areas are more susceptible to unsafe abortion practices compared to urban areas [ 6 ]. Women’s age, geographic location, gender composition of their living children, and their level of education are crucial predisposing factors influencing unsafe abortion in India [ 6 ]. A significant 27% of abortions in India are conducted at home. Notably, self-administered abortions account for 21.6% in urban areas, which starkly contrasts with the 30% in rural settings [ 4 ]. Therefore, the importance and potential scope of the use of MA medicines cannot be understated.

In India, health products are governed by the Drugs & Cosmetics Act [ 10 ], which covers a wide variety of medicines and medical devices. Mifepristone was approved under this act in 2002. In 2008, the Government of India (GoI) approved the use of co-packaged mifepristone and misoprostol products (combi-pack) for use up to nine weeks (63 days) of pregnancy. As a result of the introduction of MA medicines and subsequent widespread availability, the abortion landscape in India has changed substantially. Both mifepristone and misoprostol are considered ‘Schedule H drugs’ according to the Drugs and Cosmetics Act [ 10 ]. This means that these drugs require a written prescription by a registered medical practitioner (RMP). The specific characteristics of RMP are described within the Medical Termination of Pregnancy (MTP) Act Rules [ 1 ]. The definition of RMPs was broadened in the 2021 amendment that extended the scope of comprehensive abortion care (CAC) service provision [ 1 , 11 ]. The National Comprehensive Abortion Care Training and Service Delivery Guidelines of 2018 and 2023 provide clinical guidance for MA use [ 12 ].

In recent years, the government has invested significantly in improving the quality of medicines and strengthening its regulatory agencies at the national and state-level [ 13 ]. In stark contrast to MA drugs, contraceptives in India are supplied via a centralized system, the FP-LMIS (Family Planning Logistics, Management, and Information System). MA medicines manufacturing, procurement and distributions are decentralized and determined at the state-level. Despite the high use of MA medicines and potential for growth [ 4 ], we found no previous comprehensive assessment of this landscape. Given India’s increasing focus on strengthening its overall pharmaceutical manufacturing capacity, through this assessment, we wanted to map all available MA medicines, and identify strategic areas of intervention to highlight the unique opportunity to position the country as a leading provider of MA medicines. Given this context, it is critical to understand the landscape of MA medicines, the mechanisms for quality assurance, barriers for use and opportunities to improve access to MA medicines in India.

The objectives of the assessment were to systematically identify the regulatory landscape including manufacturing, quality assurance standards, policy and financial norms governing availability of MA medicines in the market, both nationally and at the state-level. We aimed to better understand the procurement, storage, distribution, and overall use of MA medicines whilst also reviewing the service providers knowledge and end users' awareness regarding MA. This paper also identifies opportunities for increasing availability of quality-assured MA medicines. For our paper, a quality-assured medicine was defined as one that is either WHO Prequalification (WHO PQ)-listed or approved by a Stringent Regulatory Authority (SRA-approved) [ 14 , 15 , 16 ].

This assessment was completed before the MTP amendment of 2021, but opportunities identified through this assessment are relevant for the implementation of the CAC program especially after the law change [ 11 ].

We applied the WHO country assessment protocol for MA medicines at the country-level. The assessment protocol included five steps: (1) adaptation of availability framework as per country context, (2) literature review (3) country-level key informant interviews, (4) analysis of publicly available data to identify barriers and opportunities in MA medicines availability, and (5) validation of findings by the technical advisory group (Fig.  1 ). Each step has a set of conditions that should be fulfilled to ascertain MA medicine availability and span across all aspects of use, from supply by the manufacturer to demand and use by the end user [ 17 ].

Source : Rehnström Loi, U., Prata, N., Grossman, A. et al. In-country availability of medical abortion medicines: a description of the framework and methodology of the WHO landscape assessments. Reprod Health 20 (Suppl 1), 20 (2023). https://doi.org/10.1186/s12978-022-01530-7

The five pillars of availability of a service related to a medical.

As part of this assessment, we also conducted a deep dive in two states, Rajasthan, and Tamil Nadu, to better understand the state-level differences. The state-level analysis has not been included in this paper; however, the full report is available on the WHO website. The rationale for the state selection was significant utilization of MA drugs and presence of a well-established medical service corporation.

We conducted a comprehensive desk review to collate and analyse data from secondary sources, including government reports, National Family Health Surveys, state-level program implementation plans, published research articles and evaluation reports. Primary data was collected through 45 key informant interviews representing diverse stakeholder perspective, ranging from officials from the Ministry of Health and Family Welfare (MoHFW); the Federation of Obstetric and Gynaecological Societies of India; manufacturers and distributors and including social marketing organizations; academics; clinicians; and non-governmental organizations, as well as State Health Mission representatives from two states, Tamil Nadu, and Rajasthan.

The assessment was conducted between August and November 2020 and the findings were finalized in March 2021 following validation by national experts. The assessment occurred within the context of an ongoing national dialogue on abortion laws and policies. During this period, the MTP Act of 1971 was amended and ratified as “The MTP (Amendment) Act 2021”, unrelated to the assessment itself [ 11 ].

Registration and quality assurance

The Central Drugs Standard Control Organization (CDSCO), operating under the Director General of Health Services, MoHFW, serves as the primary national regulatory authority (NRA) in India. India is an active member of the Southeast Asia Regulatory Network, which seeks to increase access to high-quality medicines including MA products in the WHO member states in the region [ 18 , 19 ].

In India, new medicines are initially registered, reviewed and then centrally approved by the drug controller under CDSCO with a restricted license issued for the period of three years [ 20 , 21 ]. If the product meets quality and compliance standards consistently over three years, the restricted license transitions to a general license, and manufacturers can seek registration of their products with the state-level Food and Drug Control Administrations (FDCA). These FDCAs are then responsible for regulation and manufacturing of MA medicines in their state. Once a product is approved by either CDSCO or state-level FDCA, it is eligible for marketing and distribution throughout the country. This also applies to MA medicines [ 10 ].

Manufacturing

CDSCO manages an e-portal named SUGAM [ 21 ], which offers the up-to-date data on approvals, licenses, and details of all medicines manufacturing facilities including information on formulations and prescribed use for Schedule H drugs. The current licensed drug list of CDSCO includes misoprostol (Sr. No. 869) which is approved for “cervical ripening, prevention of postpartum hemorrhage and first trimester abortion along with mifepristone”. The list also includes mifepristone (Sr. No. 1039) approved for use “by Gynecologist only—for medical termination of intrauterine pregnancy through 49 days of inception” and a combi-pack of mifepristone + misoprostol (Sr. No. 1782) “for the medical termination of intrauterine pregnancy of up to 63 days gestation based on the first day of the last menstrual period” [ 21 ].

We identified 42 combi-pack products by 35 manufacturers available in India discerned through manufacturers’ and social marketers’ websites and online pharmacies (Table  1 ). These products are approved by a state-level FDCAs based upon the initial combi-pack approved by CDSCO in 2008 (Sr. No. 1782), however, their exact registration status within the country could not be verified. These 35 combi-packs manufacturers are distributed nationwide, with some operating in multiple states. Two misoprostol products manufactured in India are WHO PQ-listed and one combi-pack is SRA-approved; all three products are intended for export and manufactured in dedicated facilities (Table  1 ). There is an opportunity for the local manufacturers of MA medicines towards achieving WHO-PQ, which can elevate their global contribution, enhancing access to quality MA medicines.

Quality assurance

State FDCAs in India oversee regular inspections of manufacturing sites for compliance with current good manufacturing practice (cGMP) and for monitoring adverse reactions. In India, there are two basic approvals for manufacturing facilities. One is cGMP determined by state FDCA inspections and based on the inspection risk-assessment. The other is cGMP determined by joint inspection by CDSCO Zonal Officers and inspectors using a quality risk approach and a checklist relying on the WHO cGMP scheme for pharmaceutical products, and on national Certificates of Pharmaceutical Product, also based on WHO guidelines. Both types of inspections happen approximately every three years. For hormonal products like, misoprostol, to align with WHO cGMP standards, manufacturers must maintain a dedicated hormonal facility for production.

In public sector procurement systems, quality assurance, three random samples from manufacturing sites or pharmacy registers are selected at the central warehouse. These are then dispatched to the Head Office of Drug Control and then subsequently sent to three different labs for analysis. Should medicines fail to meet assay or pharmacopeia standards, district warehouses receive directives to freeze the stock until the Quality Control Department issues further directions on next steps [ 22 ].

Policy and financing

Abortion care is integral to India’s Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) strategy and is incorporated into national service delivery guidelines and the National Health Mission (NMH) Program Implementation Plans [ 10 ]. Although robust national policies exist and guidelines on provider eligibility, capacity building and financial support for MA medicine procurement are already in place [ 1 , 11 , 12 ] state-level variations persist.

The national essential medicines list (EML) guides public sector procurement, but states have autonomy to formulate their essential medicine lists based on the specific requirements. This assessment identified that while national policy and inclusion of mifepristone and misoprostol exists, translation into state EMLs is inconsistent. For example, in Tamil Nadu, the 2019–2020 EML includes misoprostol (200 mcg tablet) and mifepristone on a separate “Specialty Drug List” for public tender – a temporary designation for newly added medicines. In Rajasthan, the 2020 EML includes mifepristone tablets for primary health centers and misoprostol tablets for sub-centers and above. However, the MTP combi-pack, not in the EML, is on an approved rate list and is procured by the Government of Rajasthan [ 23 ].

Procurement and distribution

Public sector procurement of MA medicines is devolved to the state level; there is no centralized procurement system at the national level. State governments have established corporations to procure essential medicines through bulk purchasing utilizing their NHM funds.

These funds are allocated based on Program Implementation Plans submitted by the states. During the fiscal year 2019–2020 and 2020–2021 under the budget head of ‘Drugs for Safe Abortion’ varies and is contingent on state needs and the availability of existing stock; budget needs and allocations are generally based on previous trends. Financing (including procurement) of MA medicines varies significantly across states despite national level efforts to allocate funds to purchase MA medicines.

The variation in requirement also poses challenge for procurement. States with small quantity tender volumes may not be attractive to the large manufacturers for competing for tenders. A review of a sample of public tenders at state level reveals that there is variation in combi-pack tender volumes across states. For example, in Rajasthan and Tamil Nadu, the tender volume is on average 17,000 and 15,000 combi-packs, respectively, compared to larger public-sector tenders in states like Madhya Pradesh (80,000) and Karnataka (40,000).

Besides small tender volumes, there are also other factors which dissuade commercial manufacturers from competing for public tenders, such as onerous paperwork, payment delays, and preference for in-state suppliers to promote local businesses. The non-governmental sector has an important role in procurement and distribution of MA medicines through public–private partnerships.

MA medicines are also available for purchase upon prescription through retail pharmacies. There is wide variability in the availability of MA medicines in pharmacies across states. A large-scale medicine survey of essential medicines conducted by the MoHFW in 2014–16 found that misoprostol has limited availability in retail outlets [ 24 ]. Data from NGO pharmacy surveys indicate that chemists cite strict monitoring and reporting by state-level FDCAs as reasons for ceasing to stock and dispense MA medicines in pharmacies [ 23 , 24 , 25 ]. Key informant interviews in both states corroborate the finding that documentation requirements for pharmacists (copies of prescriptions on file, client signatures) and the risk of loss of license, create barriers to pharmacists’ willingness to stock MA medicine. Pharmacies affiliated with hospitals with obstetricians and gynecologists are most likely to stock MA medicines.

The national health survey clearly shows that the majority of abortions are performed in the private health sector (53%), and only 20% in the public health sector [ 4 ]. There is a robust private sector market for MA medicines in India with not only commercial distributors but also social marketing organizations distributing and selling MA medicines through a variety of private sector providers, outlets, clinics, and pharmacies [ 25 ].

Provider knowledge and behavior

The MTP Act defines who can provide abortion in India [ 1 , 11 ]. Medical doctors are permitted to perform MTP up to 20 weeks’ gestation if they have a post-graduate degree or diploma in obstetrics and gynecology, have completed six months of residency in obstetrics and gynecology or have at least one-year experience in the practice of obstetrics and gynecology. Physicians with a Bachelor of Medicine, Bachelor of Surgery (MBBS) are only permitted to provide first trimester (up to 12 weeks’ gestation) MTP/CAC services after completing training at a government approved training center or hospital and becoming a certified provider [ 12 ].

Funding for the training of these providers is allocated under the NHM Program Implementation Plan which primarily targets training master trainers and Medical Officers. However, CAC training is inconsistent, highlighting the need for optimized fund utilization. Interviews with providers highlighted the need for innovative approaches to teaching and learning without diverting providers from service delivery.

The study reveals a significant gap in providers’ awareness of the updated national abortion guideline, and the abortion law in India [ 11 , 26 ]. Although the combi-pack is approved for use up to nine weeks (63 days) of gestation, many providers limit its use to seven weeks (49 days) of gestation, per the MTP Act. Additionally, invasive practices, like dilatation and curettage, are still commonly practiced [ 4 , 26 , 27 , 28 , 29 ]. Key informant interviews showed that knowledge of the WHO Abortion Care guideline is inconsistent. There is lack of alignment between WHO recommendations for use of MA medicines, which is up to 12–13 weeks of gestation [ 2 , 3 ], the combi-pack regulatory approval (9 weeks) and the MTP Act. This creates challenges in evidence-based decision-making in abortion care services, particularly in private sector, which often sees minimal regulatory supervision.

End user knowledge and behavior

This assessment, primarily based on literature review, indicates a significant knowledge gap regarding abortion legality and availability of safe services, particularly among young and unmarried [ 4 ]. The stigma surrounding abortion is pronounced, especially in rural areas, and the emphasis on sex-selective abortion has fostered a widespread belief that all abortions are illegal [ 4 , 28 , 29 ]. Despite free services in the public sector, many abortions take place in private sector at considerable out-of-pocket costs (retail cost ranges from 335–600 INR, equivalent to USD$4-$7.25), due to unawareness about free services in public sector [ 30 , 31 ]. Woman’s negative perceptions of the legality, quality, privacy and confidentiality, and hostile public facility environment deter women from accessing public sector services, often resulting in unsafe abortion practices [ 4 , 30 , 31 , 32 ].

Community awareness activities about safe abortion services is not uniformly prioritized and varies across the state-level. The Reproductive, Maternal, Newborn, Child and Adolescent Health program calls for, “Routine orientation and training of Accredited Social Health Activists to equip them with skills to create awareness about abortion issues in the community and facilitation of women's access to services”, yet dedicated funding for this initiative is often absent.

Discussion and recommendations

This paper is the first landscape assessment of MA medicines, particularly the combi-pack, using the WHO framework for assessing the availability of MA medicines. This is a standardized, evidence-based approach that not only identifies areas of intervention along the supply-chain but also provides significant opportunities for establishing India’s potential in providing quality-assured MA medicines for the Region and the world.

India is an important manufacturer of MA medicines [ 22 , 23 ]. However, we found that uniform implementation of quality assurance and regulatory procedures requires strengthening at the national and state-levels. This is well within the scope of authority of the national regulatory body. While CDSCO oversees and coordinates state FDCA more nuanced attention on MA medicines is needed to reduce the variation between the enforcement and uptake of regulatory standards. This, combined with a lack of structured norms defining state EMLs and the national EML, creates discrepancies that add undue barriers to public sector procurement and availability of MA medicines.

Combi-packs in India are approved by state-level regulatory agencies with oversight by CDSCO. Manufacturing a quality misoprostol product is challenging as pure misoprostol is extremely unstable and easily degraded by moisture [ 33 , 34 , 35 ]. While requirements for the quality testing of MA medicines are in place, including during manufacturing and immediately post-procurement, this may not be sufficient to determine a level of quality of MA products that can be upheld up to international standards. Medicines procured by state agencies have been found to be monitored for their quality prior to distribution for public sector facilities. However, state procurement agencies may miss potential quality issues of combi-pack and misoprostol tablets with only baseline testing upon receipt of medicines at warehouses [ 13 , 33 ]. To improve overall quality of MA medicines, quality control should be replaced by quality assurance at all stages of manufacturing and strengthened implementation of cGMP should be ensured across manufacturing sites.

WHO provides technical assistance to local manufacturers, including capacity building for cGMP, to support a WHO-PQ application process and foster local production. MA medicine manufacturers could apply for WHO PQ either for finished pharmaceutical products, which would facilitate procurement of their medicines outside of India, or for or active pharmaceutical ingredients, which would support manufacturing of quality medicines internationally. Manufacturers could also consider applying for approval from additional SRAs, if they have the manufacturing capacity and meet CDSCO export conditions, to cater to the global demand for MA medicines.

Procurement of MA medicines by states does not guarantee availability of MA medicines at public facilities or public sector pharmacies. Regional tendering for procurement may create a market size that would entice small and mid-level manufacturers to compete. Specific interventions at the state-level, such as streamlining the payment process, e-tendering, and capacity building for tendering processes and streamlining supply chain aspects and other initiatives may overcome the barriers dissuading commercial manufacturers from competing for tenders. Public sector procurement capacity should be strengthened to ensure that enough combi-packs are available at approved MTP public sector sites. All states should capitalize upon available resources for MA medicine and improve the quantification and forecasting of MA medicines.

Since 2015, WHO has published or updated multiple guidelines with new and rigorous evidence which could be considered for national uptake [ 2 , 3 , 33 , 34 , 35 , 36 ]. The updated MTP amendment provides an opportunity for updating and aligning national guidelines in India with global evidence-based recommendations. CAC training, in addition to being skill-based, must also be designed to clarify values, address social stigma, and provide comprehensive abortion services care, with quality, safety and most importantly respect [ 37 , 38 , 39 ]. Finally, states may introduce focused awareness campaigns to address the inaccurate conflation of laws and its effect on the correct provision of abortion care and invest in raising community awareness about the legality of abortion and availability of free safe abortion care service in public health facilities.

Limitations and strengths

This assessment provides the first overview of the MA medicines landscape in India. The implementation of a previously tested WHO framework in other countries creates structure and comparability across contexts [ 17 ]. Furthermore, the methodology can be easily replicated to determine changes in the landscape. A limitation to the assessment, due to the COVID-19 pandemic, was that interviews were largely conducted virtually or by telephone. Validity to determine the extent to which it accurately measures what it intends to measure was beyond the scope of the current paper.

Some interviews, notably with Food and Drug Control Administrations, could not be secured, limiting information collected to publicly available documents and expert feedback. This is relevant as the current registration status of the products listed in Table  1 is devolved to the state-level and could not be verified. End-user knowledge and behaviors could not be assessed owing to the pandemic. This may have limited the capture of the full spectrum of availability and quality of MA medicines in India. Finally, this assessment did not include analysis of export functions, current export volume, and manufacturers that export medicines, it was focused on domestic policy, supply, and procurement only.

India benefits from strong national policies that center abortion care within the National Health Mission, its budgets and guidelines. India's prominence as a leading manufacturer of MA medicines guarantees a steady product supply. However, there is variation across states and this landscape assessment uncovers opportunities to enhance the availability of quality MA medicine in India. These opportunities include uniform implementation of regulatory standards, prioritizing quality-assurance during manufacturing process especially for misoprostol and establishing standardized procurement and supply chain norms across all states. Streamlining implementation efforts on laws, policies and guidelines governing MTP and MA, with regular in-service training of providers on medical abortion provision in line with the latest national guidelines is required. Additionally, evidence dissemination and regular community engagement about the recently amended abortion law is needed.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author, LL, upon reasonable request.

Abbreviations

Active pharmaceutical ingredient

Central Drugs Standard Control Organization

Comprehensive Abortion Care

Current good manufacturing practice

Essential Medicines List

Food and Drug Control Administrations

Medical Abortion

Bachelor of Medicine, Bachelor of Surgery

Medical Termination of Pregnancy

Ministries of Health and Family Welfare

National Health Mission

National Regulatory Agency

Registered medical practitioner

Reproductive, Maternal, Newborn, Child and Adolescent Health

Southeast Asia Regulatory Network

Stringent Regulatory Authority

World Health Organization

WHO Prequalification

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Acknowledgements

We wish to acknowledge the time and commitment of those organizations, government entities and individuals who provided valuable insights that informed the overall report. We wish to thank VSHD consultants, Sachin Juneja and Rajalakshmi RamPrakash for their significant contributions to conducting data collection and key informant interviews in the states of Rajasthan and Tamil Nadu, respectively. Sadab Boghani, National Consultant for CAC, WHO India who helped draft the original report and supported with the validation and clearances from all appropriate authorities. Finally, we would like to acknowledge the unyielding technical support and guidance from the WHO Country Office for India that made this work possible including but not limited to Dr Hilde De Graeve, Team Lead Health Systems and the WHO SAMARTH Team –Dr Pragati Singh, Dr Nidhi Bhatt, Ms Shikha Bansal, Dr Ashish Bhat, Dr Richa Kandpal, Dr Rakshita Khanijou, Ms Sapna Dubey and Ms Priya Kapur who supported this work immensely. We also acknowledge the support and guidance of Dr Sumita Ghosh, Additional Commissioner and In-charge Comprehensive Abortion Care at the Ministry of Health and Family Welfare, Government of India (at the time of the report); President of Federation of Obstetrician and Gynecological Societies of India Dr Shantha Kumari; Mission Directors and Nodal Officers from the States of Tamil Nadu and Assam; Ms Payden and Dr Rodercio Ofrin from WHO Country Office for India; Dr Meera Upadhyay and Dr Neena Raina from the WHO Regional Office for South-East Asia.

About this supplement

This article has been published as part of Reproductive Health Volume 20 Supplement 1, 2023: Availability of quality-assured medical abortion medicines no internal references. The full contents of the supplement are available online at https://reproductive-healthjournal.biomedcentral.com/articles/supplements/volume-20-supplement-1 .

This work was supported by the UNDP–UNFPA–UNICEF–WHO–World Bank Special Programme of Research, Development and Research Training in Human Reproduction, a cosponsored programme executed by the WHO. The views expressed in this article are those of the authors and do not necessarily represent the views of, and should not be attributed to, the World Health Organization.

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Priya Karna, Madhur Gupta, Tapas Chatterjee & Pushpa Chaudhary

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K. Aparna Sharma

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Amy Grossman, Natalie Williams & Ndola Prata

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Annik Sorhaindo, Laurence Läser, Ulrika Rehnström Loi & Bela Ganatra

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The landscape assessment was conceptualized by URL, BG and AFL. The VSHD Availability Framework was developed by NP and the indicators were adapted for medical abortion commodities by NP, AG and NW. PK, AG, AS, KAS, and TC drafted the manuscript with significant contributions from URL, LS and BG. All authors reviewed and edited versions of the manuscript. PK, AS, AG and TC had full access to all the data and had final responsibility for the decision to submit for publication. The authors alone are responsible for the views expressed in this article, and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. All authors read and approved the final manuscript.

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Ethics approval was not applicable as the landscape assessment was led by the Ministry of Health as programme assessment and not conducted as research activity. The information collected during the desk review is publicly available data and the key informants all participated within their official capacity and were selected by the Ministry of Health. Verbal informed consent to participate in the assessment was obtained from all participants.

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Karna, P., Sharma, K.A., Grossman, A. et al. Landscape assessment of the availability of medical abortion medicines in India. Reprod Health 20 (Suppl 1), 193 (2023). https://doi.org/10.1186/s12978-024-01774-5

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• Volume 4, Issue 3
• Unsafe abortion and abortion-related death among 1.8 million women in India
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• Ryo Yokoe 1 ,
• Rachel Rowe 2 ,
• Saswati Sanyal Choudhury 3 ,
• Anjali Rani 4 ,
• Farzana Zahir 5 ,
• http://orcid.org/0000-0003-0660-5054 Manisha Nair 2
• 1 Nuffield Department of Population Health , University of Oxford , Oxford , UK
• 2 NPEU, Nuffield Department of Population Health , University of Oxford , Oxford , UK
• 3 Department of Obstetrics and Gynaecology , Guwahati Medical College and Hospital , Guwahati , India
• 4 Department of Obstetrics and Gynaecology , Institute of Medical Sciences, Banaras Hindu University , Varanasi , India
• 5 Department of Obstetrics and Gynaecology , Assam Medical College , Dibrugarh , India
• Correspondence to Dr Manisha Nair; manisha.nair{at}npeu.ox.ac.uk

Introduction Unsafe abortion is a preventable cause of maternal mortality. While studies report high number of abortions in India, the population-level rates of unsafe abortion and their risk factors are not well understood. Our objective was to analyse the rates of and risk factors for unsafe abortion and abortion-related maternal death in India.

Methods We conducted a secondary analysis of data from 1 876 462 pregnant women aged 15–58 years from nine states in the Indian Annual Health Survey (2010–2013). We calculated the rate of unsafe abortion and abortion-related mortality with 95% CI. Multivariable logistic regression models examined the associations of sociodemographic characteristics, health seeking behaviours and family planning with unsafe abortion and abortion-related mortality.

Results There were 89 447 abortions among 1 876 462 pregnant women in 2007–2011 (4.8%; 95% CI 4.8 to 4.9). Of these, 58 266 were classified as unsafe (67.1%; 95% CI 66.7 to 67.5). There were 253 abortion-related maternal deaths (0.3%; 95% CI 0.2 to 0.3). Factors associated with unsafe abortion: maternal age 20–24 years (adjusted OR (aOR): 1.13; 95% CI 1.09 to 1.18), illiteracy (aOR: 1.48; 95% CI 1.39 to 1.59), rural residence (aOR: 1.26; 95% CI 1.21 to 1.32), Muslim religion (aOR: 1.16; 95% CI 1.12 to 1.22), Schedule caste social group (aOR: 1.08; 95% CI 1.04 to 1.12), poorest asset quintile (aOR: 1.45; 95% CI 1.38 to 1.53), antenatal care (aOR: 0.69; 95% CI 0.67 to 0.72), no surviving children (aOR: 1.30; 95% CI 1.16 to 1.46), all surviving children being female (aOR: 1.12; 95% CI 1.07 to 1.17), use of family planning methods (aOR: 0.69; 95% CI 0.66 to 0.71). Factors associated with abortion-related deaths: maternal age 15–19 (aOR: 7.79; 95% CI 2.73 to 22.23), rural residence (aOR: 3.28; 95% CI 1.76 to 6.11), Schedule tribe social group (aOR: 4.06; 95% CI 1.39 to 11.87).

Conclusion Despite abortion being legal, the high estimated prevalence of unsafe abortion demonstrates a major public health problem in India. Socioeconomic vulnerability and inadequate access to healthcare services combine to leave large numbers of women at risk of unsafe abortion and abortion-related death.

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Key questions

What is already known.

There is a high prevalence of unsafe abortion in India, but population level rates and risk factors are not clearly understood.

What are the new findings?

67% of abortions in the study population in India were classified as unsafe, varying widely across the states (range 45.1%–78.3%).

There was a disproportionately higher risk of unsafe abortion among the vulnerable and disadvantaged populations in India.

Young women aged 15–19 years were at the highest risk of dying from an abortion-related complication.

What do the new findings imply?

Urgent work is needed to understand the barriers to safe abortion in India, despite the conducive legal environment.

Introduction

Unsafe abortion is one of the preventable causes of maternal mortality 1 yet, of the 55.7 million abortions that occurred globally each year between 2010 and 2014, an estimated 25.1 million (45.1%) were unsafe. 2 Defined by the WHO as “the termination of an unintended pregnancy either by persons lacking the necessary skills or in an environment lacking the minimum medical standards or both,” 3 unsafe abortion is strongly associated with maternal complications such as haemorrhage, sepsis and trauma, and is the fourth leading cause of maternal death. 4 Abortion plays a crucial role in the reproductive health of Indian women. 5 An estimated 15·6 million abortions (14.1 million–17.3 million) were conducted in India in 2015. Women in India often turn to unqualified providers for abortion, 6 despite abortion being made legal in the country through the Medical Termination of Pregnancy Act in the early 1970s. 7 While several studies suggest a high prevalence of unsafe abortion and related complications among women of reproductive age group in India, 2 6 8 9 population-level rates of unsafe abortion and abortion-related mortality, and their risk factors are not well understood.

Previous research and theoretical arguments on abortion in India point to three main and interrelated factors that are important in understanding the context of seeking abortion: (1) women’s labour force participation and educational attainment; (2) women’s social class and ethnicity; (3) the predominant preference for male children. 10 However, the combined effect of these factors has not been tested empirically. This is crucial to identify populations that are at a higher risk of seeking unsafe abortion in India to prevent maternal complications and deaths. The objectives of this study were to: (1) estimate the rates of unsafe abortion and abortion-related maternal mortality in nine states in India; (2) examine the sociodemographic characteristics of women who have an abortion compared with women who have a live birth; (3) investigate the risk factors for unsafe abortion; (4) investigate the risk factors for abortion-related maternal death in India.

We conducted a secondary data analysis of the 2010–2013 round of India’s Annual Health Survey (AHS) to analyse the rate of and risk factors for unsafe abortion and abortion-related maternal deaths in nine states in India.

Definitions

Based on the WHO definition, we used three criteria to identify ‘unsafe abortions’ using AHS data: (1) the setting where the abortion was performed (if induced) or completed (if spontaneous); (2) the person who performed or completed the abortion; (3) the gestational age at which the abortion was performed or completed. Abortions were classified as unsafe if they were not performed or completed in a health facility, not performed or completed by a skilled birth attendant, or performed or completed at 20 weeks of gestation (~5 months) or beyond. Abortions at or beyond 20 weeks’ gestation were classified as unsafe because of the association with increased risk of maternal morbidity and mortality 11 and because abortion beyond 20 weeks of pregnancy is illegal in India and under such a condition woman may be forced to seek abortion services from unqualified providers. The breakdown of unsafe abortion according to the three criteria is presented in online supplementary table S1 .

Supplemental material

We combined induced and spontaneous abortion into one category to minimise the risk of misclassification 3 10 as most induced abortions are unreported or reported as spontaneous in surveys for legal, ethical and moral reasons. 12 13 Further, it was considered that determining safety of abortion was more important than examining types of abortion. Rees et al have argued that both induced and spontaneous abortion can result in unsafe abortion and present with complications. 14

Data source

We used AHS (2010–2013) data. The AHS is a population-based household survey in which self-reported data on maternal and child health, demographics, birth and access to health and family planning services were collected from 4.3 million households in nine less developed states of India (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand and Assam), representing 50% of the country’s population, 61% of births and 62% of maternal deaths. 15 16 The AHS used a stratified simple random sampling (without replacement) to obtain a sample that was representative of and proportional to the size of the selected villages. Survey weights were developed to account for the sampling method. The survey administered four ‘schedules’ (or questionnaires): (1) House-listing Schedule, (2) Household Schedule, (3) Women Schedule and (4) Mortality Schedule. Relevant data from all four schedules were merged for this study. Detailed objectives and associated methodology can be found in the AHS Report (Part I. 2014). 16

Study sample

All women who provided information on their pregnancy (91.3% most recent pregnancy and 8.7% on a previous pregnancy) were included. As in a previous study using the same dataset, women who had an abortion after 28 weeks were excluded as these were most likely to be stillbirths (according to the WHO definition for stillbirth). 15 A total of 1 876 462 women who reported being pregnant during the reference period 2007–2011 were included in the study. The mortality data were extracted from the mortality Schedule of the AHS and 253 abortion-related deaths were included, giving a total of 89 447 abortions in 2007–2011. Among these, 253 women who died and 83 women who survived did not have information to examine the safety of abortion. Therefore, safety of abortion was examined in a total of 89 111 women, of which 58 266 had unsafe abortions and 30 845 had safe abortions. online supplementary figure S1 further illustrates how we derived the samples for each study objective.

Potential risk factors for unsafe abortion and abortion-related deaths

We conducted a systematic search and review of the literature to identify risk factors for unsafe abortion and abortion-related death. Informed by the literature review, we developed conceptual frameworks to map the relationships of the risk factors with unsafe abortion ( online supplementary file 1 ) and abortion-related mortality ( online supplementary file 1 ) according to proximity to the outcome, and to guide selection of variables and analysis. Based on the literature review and conceptual frameworks, we grouped the population characteristics/potential risk factors as sociodemographic characteristics, pregnancy-related characteristics, family characteristics, the use of family planning methods, and health seeking behaviours and mapped these against the available data in the AHS. We used survey data about household assets and principle component analysis 17 to derive a measure of household wealth which is thought to be a good proxy of economic status. 18 19 We used data about the number of surviving children and the number of female children to derive the proportion of surviving female children. We considered the following as potential risk factors for unsafe abortion and/or abortion-related death: use of family planning method; place of residence; social group; religion; asset index/wealth; number of total surviving children; proportion of female children; maternal age; maternal education status; antenatal care (ANC) use; marital status; maternal employment; gestational month of abortion. The variables and their categorisation are described in online supplementary file 1 . All independent variables reflect characteristics of the household or women at the point of the survey. Baseline groups were chosen as the group with the least potential risk of having unsafe abortion, except for the use of family planning methods and the use of ANC (baseline—higher potential risk).

Statistical analysis

There were three outcomes of interest: (1) the outcome of the woman’s pregnancy (live birth or abortion); (2) the safety of abortion (safe or unsafe); (3) the outcome of abortion (survived or died). The rate of abortion, unsafe abortion, and abortion-related death and the corresponding 95% CIs were calculated. The denominator for abortion rate was the total number of pregnancies in the reference period (2007–2011), and for the rates of unsafe abortion and abortion-related death was the total number of abortions during the same reference period. The characteristics of women who had an abortion were compared with those who had a live birth. We used univariable logistic regression analysis to examine the association between each independent variable and the outcomes (unsafe abortion and abortion-related mortality). Modelling a non-linear association between maternal age and the outcomes using fractional polynomials showed that maternal age acted in a non-linear fashion and was therefore used as a categorical variable.

Multivariable models were built using a stepwise forward regression approach, with our conceptual frameworks used to select the order for including the variables starting from distal to proximal ( online supplementary figures S2 and S3 ). During model building for unsafe abortion we used a p value <0.05 in the univariable analysis as a cut-off for including a variable. We used the Wald test at the 5% significance level to determine if adding a variable significantly improved the model fit. In the multivariable model examining the risk factors for abortion-related death we chose to include all six potential risk factors, regardless of the results of the univariable analysis, because the number of variables available in the mortality dataset was small, and in order to control for confounding effects. Factors whose effects were attenuated by other variables in the multivariable regression were further examined to identify confounding. We calculated the proportion of factors reported to contribute to abortion-related maternal death.

Collinearity between independent variables was explored using pairwise correlation coefficients. We tested for interactions between variables for which there was a strong theoretical rationale. In the risk factor analysis for unsafe abortion, we therefore tested for interactions between employment and residence, employment and wealth, and social group and wealth. In the risk factor analysis for abortion-related mortality, interactions between social group and wealth, and social group and residence were examined. Potential interactions observed using univariable logistic regression were further assessed using the Wald test comparing the multivariable model with the relevant interaction terms with an empty model. No significant interactions were found at the 5% significance level.

We carried out an exploratory post hoc subgroup analysis to investigate the effect of the number of surviving female children in households where all children were female on the odds of unsafe abortion. All statistical analyses were carried out using Stata V.13.1 using the ‘ svy set’ function to account for the stratified and clustered nature of the data. All proportions, means and CIs presented are therefore weighted for design effects and non-response. Two-sided p values <0.05 were taken to indicate statistical significance.

Missing observations per variable were quantified, and we explored the ‘type of missingness’ by generating a new variable indicating missing data for each risk factor followed by logistic regression analysis to identify factors that predicted missingness. Based on this analysis, data were assumed to be ‘missing at random’ and three methods were used to address bias due to missing data: missing indicator method, complete case analysis and multiple imputation. 20 The ‘missing indicator’ model in which missing data were grouped as a separate category was used as the final model. However, to maintain model stability, for variables that had <1% missing data, a separate category for ‘missing’ was not generated.

Study power

For the fixed sample size of 89 111 women who were classified as having a safe abortion and 58 266 who had an unsafe abortion, this study had 90% power to detect an OR of ≥1.29 or ≤0.75 associated with unsafe abortion at p<0.05 (two-tailed) for the risk factor with the lowest prevalence (‘other religion’ 0.6%), and an OR of ≥1.43 or ≤0.74 for the risk factor with the highest prevalence (‘being married’ 99.6%) in the study population.

For the fixed sample size of 89 447 women who had an abortion and survived and 253 women who died during or within 42 days of the abortion procedure, this study had 80% power to detect an OR of ≥3.00 associated with abortion-related death at p<0.05 (two-tailed) for the risk factor with the lowest prevalence (‘Christian religious group’ 0.6%), but not enough power to detect an OR less than one at a clinically meaningful level. This study had 80% power to detect an OR of ≥1.43 or ≤0.74 for the risk factor with the highest prevalence (gestational month of abortion <5; 99.6%) in the study population.

Patient and public involvement

This is not applicable since this was a secondary analysis of anonymous survey data.

Rate of abortion, unsafe abortion and abortion-related mortality

Among a total of 1 876 462 pregnant women in the study population, 89 194 women had an abortion leading to an overall rate of 4.8% (95% CI 4.8 to 4.9). The rate of abortion for each state is shown in table 1 . The prevalence of abortion was highest in Assam (6.5%) and the lowest in Chhattisgarh (1.6%). Out of 89 111 women who survived and had sufficient information to examine the safety of abortion, 58 266 women were classified as having an unsafe abortion. The overall rate of unsafe abortion was 67.1% (95% CI 66.7 to 67.5) with five out of nine states above the overall rate ( online supplementary table S3 , figure 1 ). There was a large variation in the rate across the states: Assam had the lowest (45.1%) and Chhattisgarh has the highest rate of unsafe abortion (78.3%). Among a total of 89 194 women who had an abortion, 253 were reported as abortion-related maternal death in the AHS, giving an abortion-related mortality rate of 0.3% (95% CI 0.2 to 0.3) ( online supplementary table S4 ).

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Number and rate of abortion in nine states in India, using the AHS 2012–2013

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Rate of unsafe abortion in nine states in India.

The characteristics of women who had an abortion and those who had a live birth are presented in table 2 . Overall, despite statistically significant differences because of the large sample size, there were no clinically meaningful differences in age, education, residence, religion or social class background between the two groups. Two factors showed wide variation between the abortion and live birth groups. While 85.1% of women who had a live birth reported having some ANC, only 23.1% of women who had an abortion had ANC. This was true even after excluding women who had an early abortion (<12 weeks). Also, a marginally higher proportion of women who had an abortion belonged to the highest quintiles of the asset index.

Characteristics of the study population by pregnancy outcome

Risk factors for unsafe abortion in India

The characteristics of the women who had an unsafe abortion and those who had a safe abortion are described in table 3 . All sociodemographic characteristics (except marital status and maternal employment status) and all other characteristics (except self-reported mental illness) were found to be statistically significantly associated with unsafe abortion, and these associations were not substantially altered after adjustment for all potential risk factors ( table 3 ).

Unadjusted and adjusted associations between sociodemographic and family characteristics, health seeking behaviour, family planning and unsafe abortion

Compared with women aged 25–29 years, the adjusted odds of unsafe abortion were 13% higher for younger women (20–24 years), and 18% lower for older women (35–39 and 40–44 years). Women living in rural settings had 26% higher odd of unsafe abortion compared with women living in urban settings. Muslim, Christian, or ‘other’ stated religion were associated with increased odds of unsafe abortion compared with Hindu. Education was inversely associated with unsafe abortion; women with no education were 48% more likely to have an unsafe abortion compared with women with university education or higher. Poorer women (in the lowest asset index quintile) had 45% higher odds of unsafe abortion, compared with women in the highest quintile.

In the univariable analysis, belonging to Schedule caste and Schedule tribe social groups was associated with a higher odds of unsafe abortion compared with the ‘other’ social groups. After adjusting for other risk factors the higher odds of unsafe abortion remained for the Schedule caste group, but for the Schedule tribe social group the association was reversed, with this group having 14% lower odds of unsafe abortion compared with the ‘other’ social group. Further analysis showed that the substantial change in the adjusted OR (aOR) was largely explained by the confounding effect of asset index (or wealth quintiles).

Women who had no children at the point of interview had a 30% higher odds of having unsafe abortion compared with women who had one to three children. Compared with women whose children were all boys, women with all female children had 12% higher odds of having an unsafe abortion. This association was not significant if the woman had at least one surviving male child. On further examination through a subgroup analysis, we did not find any significant association between the number of surviving female children and unsafe abortion in households with all female children.

After adjusting for other risk factors, reported use of family planning methods at the point of survey was associated with a 21% lower odds of unsafe abortion. Women who had used ANC had 31% lower odds of unsafe abortion compared with those who did not use ANC. The results of complete case analysis and multiple imputations were not materially different from the ‘missing indicator’ model ( online supplementary table S5 ).

Risk factors for abortion-related maternal deaths in India

Of the six potential risk factors investigated (maternal age, place of residence, religion, social group, wealth/asset index, gestational month), five were statistically significantly associated with abortion-related death ( table 4 ). We found a non-linear (U-shaped) association between mother’s age and abortion-related death ( online supplementary figure S4 ). Compared with women aged 25–29 years, the aOR for abortion-related death was approximately eight times higher for women aged <20 years, and two times and four times higher for women aged 40–44, and ≥45 years, respectively. Women belonging to a Schedule tribe social group were four times as likely to die during or after having an abortion compared with the reference ‘other’ social group, but the association was not statistically significant for women belonging to a Schedule caste social group (OR: 1.38; 95% CI 0.52 to 3.66). Living in rural areas was associated with a higher odd of abortion-related death (aOR: 3.28; 95% CI 1.76 to 6.11). While the results of our missing indicator analysis were not materially different from the other models, one notable difference was that in the complete case model women who had an abortion at a gestational age of ≥5 months had a significantly higher odds of dying compared with women who had an abortion before 5 months (aOR: 4.35; 95% CI 2.53 to 7.50) ( online supplementary table S6 ).

Unadjusted and adjusted associations between sociodemographic characteristics, gestational age at abortion and abortion-related maternal death

Further analysis of factors contributing to abortion-related maternal death showed that a third of the deaths were due to delays in receiving care at the health facility, 19% were due to inadequate care at health facility and 17% were due to a failure to recognise the seriousness of the condition ( online supplementary table S7 ).

Main findings

To our knowledge, this study is the first large population-based study to examine unsafe abortion and abortion-related morality in India. The overall rate of abortion was estimated to be 4.8%, ranging from 1.6% to 6.5% among the nine states. Overall, 67.1% of abortions were classified to be unsafe, varying widely across the states with the highest being 78.3% and the lowest being 45.1%. The overall rate of abortion-related death was estimated to be 0.3% and did not vary appreciably across the states.

There were no clinically meaningful differences between women who had an abortion and those who had a live birth, but a significantly lower proportion of the women who had an abortion had ANC, and a higher proportion were educated and belonged to higher socioeconomic status. We found a strong association of unsafe abortion with sociodemographic factors (younger maternal age, lower socioeconomic status, Muslim religion, rural residence, illiteracy, schedule caste social group), healthcare service utilisation (ANC), family characteristics (number of surviving children and proportion of surviving female children) and family planning use. We found that factors associated with unsafe abortions were different from those associated with abortion-related mortality. Teenage women (aged 15–19 years) were found to have the highest risk of abortion-related death in addition to rural residence and lower socioeconomic status.

Strengths and limitations

Use of data from the AHS, the largest health survey in India, allowed us to conduct an adequately powered, robust investigation of a wide range of potential risk factors. Our findings are reasonably generalisable for high burden states, but may not be generalisable to the rest of India. To our knowledge, this study is the first in India to identify risk factors associated with unsafe abortion and abortion-related death at a population level.

The rate of unsafe abortion and abortion-related mortality may be underestimated due to underreporting of abortion and misclassification of abortion-related death. Women are often reluctant to report induced abortion regardless of the legal context of abortion. 12 13 Similarly, women might have provided inaccurate information on the three criteria used to classify the safety of abortion. Since the cause of maternal mortality was reported by family members without validation, deaths occurring after having an abortion might have been misclassified as death caused by haemorrhage or pregnancy-related deaths. In an effort to minimise the possibility of misclassification between abortion and stillbirth, women who reported having an abortion after 28 weeks were excluded.

As the survey design was cross-sectional, causality cannot be inferred from the study results. We did not have data on the method of abortion, therefore this could not be used as a criterion for classifying the safety of abortion. However, methods used to estimate unsafe abortion rates vary widely across studies, 2 21–24 and there are discrepancies between how the WHO definition is worded and how it has been practically applied to measure the burden of unsafe abortion. 25 Because there were some factors identified in the literature as important risk factors for unsafe abortion (including, eg, sexual behaviour, partners’ approval of abortion, reasons for abortion, pregnancy wantedness and exposure to media), for which data from the AHS were not available, there is a risk of residual confounding. Finally, because death is a rare outcome, this study had restricted statistical power to detect significant associations between risk factors and abortion-related death.

Other evidence and implications

Our estimates of the prevalence of unsafe abortion in these nine Indian states fit with regional estimates from a study in south-central Asia (57.8%; 95% CI 50.3 to 65.9), 2 but are much higher than in a study conducted in India using data from the 2015 Health Facilities Survey and national abortion medication sales, which concluded that among 15.6 million abortions occurring in 2015, 0.8 million (5%) abortions were unsafe. 8 This discrepancy is possibly because in this latter study unsafe abortion was defined only as a surgical abortion performed outside of a health facility, without considering who performed the abortion or when the abortion was performed.

Our results suggest a pervading theme of vulnerability for unsafe abortion related to low socioeconomic status and teenage pregnancy. While there was an increased prevalence of abortion among educated women, the risks of unsafe abortion, and of death related to abortion, were higher among uneducated women, consistent with previous literature. 22 26 Although the prevalence of abortion was higher among women with higher socioeconomic status, women from lower socioeconomic status, and ‘Schedule caste’ social group, were more likely to have an unsafe abortion, and to die from abortion-related causes. This is consistent with evidence showing that disadvantaged minority groups in Brazil are at a higher risk of unsafe abortion. 22 Our finding that women belonging to ‘Schedule tribe’ groups were less likely to have an unsafe abortion might be explained by different health seeking behaviours in women from these groups or may have arisen due to residual confounding. Nevertheless, the risk of abortion-related death was higher in both social groups, indicating the possibility of disparities in access to adequate healthcare for management of abortion complications.

The importance of access to adequate healthcare is also highlighted by our findings on place of residence. Compared with women in urban settings, women living in rural settings were more likely to have an unsafe abortion and more likely to die from an abortion-related cause. More than half (56.28%) of the abortion-related deaths in this study were due to a lack of access to appropriate healthcare (ie, delay in receiving healthcare at facility, inadequate care at health facility and lack of transport to the facility). About 70% of India’s population live in rural settings, but safe abortion services are rarely available at rural facilities. 21 In the state of Rajasthan, for example, rural settings had an estimated 0.85 certified abortion facilities per 100 000 population, compared with 3.65 in urban settings. 27

Lack of access to appropriate health services is also reflected in our results in other ways. Our complete case analysis showed that gestational age at the time of the abortion was found to be one of the strongest risk factors for abortion-related mortality, which is consistent with the finding of one study conducted in the USA. 11 Although it was not possible to examine the safety of abortion among women who died, this variable serves as a proxy for unsafe abortion, supporting the evidence that an abortion-related death is most likely to occur after an unsafe abortion. 14 The process of seeking an abortion, or care for complications of spontaneous or induced abortion, can involve multiple visits to different providers, resulting in delays, with potentially devastating consequences. 28–30 In India, preventing unwanted pregnancies through family planning is a key strategy for reducing abortion rates. 31 32 Access to family planning services, may also be important for reducing the risks of having an unsafe abortion. 23 33 34 Finally, our results also suggest that antenatal check-ups may be important in reducing the risk of maternal morbidity and mortality resulting from complications, even if they plan to seek an abortion.

Beside socioeconomic factors, women’s age was significantly associated with unsafe abortion and abortion-related death. Younger women (≤24 years) were at a higher risk of unsafe abortion and risk of abortion-related death was highest among teenage women (15–19 years). Older women (≥30 years) were less likely to have an unsafe abortion, but were more likely to die as a result of an abortion. Other studies, in Bangladesh 26 and Nigeria, 35 found similar results in relation to maternal age and unsafe abortion. Although female selective abortion (FSA) is illegal in India, the practice is still prevalent. 36–38 Our finding that women with no male children were more likely to have an unsafe abortion compared with women who had at least one male child is consistent with FSA being sought from unregistered and unqualified abortion providers. 3 39

The high estimated prevalence of unsafe abortion in India demonstrates a critical public health problem. Consistent with research in other low-and-middle income countries (LMICs), our results demonstrate that socioeconomic vulnerability, teenage pregnancy and inadequate access to healthcare services combine to leave large numbers of women at risk of unsafe abortion and abortion-related death. There is an urgent need to ensure adequate access to family planning, early abortion services and adequate care for management of postabortion complications, particularly in disadvantaged areas. Further research providing empirical evidence on the barriers to safe abortion services in India is essential to reduce unsafe abortions and deaths, particularly in populations identified to be at a higher risk.

Acknowledgments

We thank Noon Altijani, DPhil student at the Nuffield Department of Population Health (NDPH) and Charles Opondo, Researcher in Statistics and Epidemiology, National Perinatal Epidemiology Unit, NDPH, for their help with survey commands and multiple imputation analysis, respectively. The AHS was conducted by the Office of the Registrar General & Census Commissioner, India ( http://censusindia.gov.in/vital_statistics/AHSBulletins/ahs.html ). We obtained the data from the Indian Government’s Data Sharing Portal where the anonymised data is freely available for research and other purposes.

• Grimes DA ,
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Handling editor Seye Abimbola

Contributors RY reviewed the literature, conducted the analysis and wrote the first draft of the manuscript. MN led the conceptualisation of the project, compiled the data, supervised the data analysis, interpretation and discussion of the results, and edited the paper. RR supervised the data analysis, interpretation and discussion of the results, and edited the paper. SSC, FZ and AR contributed to interpreting the data, and editing the paper.

Funding The study was funded by a Medical Research Council Career Development Award to Manisha Nair (Grant Ref: MR/P022030/1). The funder had no role in the study design, data analysis, data interpretation, or writing of the report. MN had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Competing interests None declared.

Patient consent for publication Not required.

Ethics approval The anonymised data are freely available through the Indian Government’s Data Sharing Portal.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement Data are available in a public, open access repository.

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Abortion in India: legal, but not a woman’s right

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On the surface, India has one of the world’s highest abortion rates and most progressive abortion laws, but this hides a tangle of issues that prevent many women from accessing safe abortion. Geetanjali Krishna reports

“I wanted to be sterilised when my second set of twins was born,” says Maina Devi. “But my family said that life in our village is too uncertain for such things.”

Devi is a 25 year old farmer from Jamunipur, a hamlet in the northern Indian state of Uttar Pradesh, who has two sets of twins under 5 years of age. Her husband refuses to use contraception. She’s not aware that, during her second pregnancy, she could have opted for abortion on the grounds of contraceptive failure. All she does now is pray that she doesn’t get pregnant again.

About 885 miles south, Anusha Pilli, a Hyderabad based medic and public health professional, is struck by the lack of awareness about abortion in the city, even among middle class college graduates. “Few of them know about medical abortion drugs available to them, or about the gestation period up to which abortion is legally allowed in India,” she says. “It’s hard to imagine that Indian law has legally allowed abortion for over 50 years—and still women have not felt empowered by it.”

On International Safe Abortion Day on 28 September 2022, the Supreme Court of India extended the right to legal abortion to 20 weeks’ gestation for all women and to 24 weeks’ gestation under special circumstances. 1 2 With this change, India’s Medical Termination of Pregnancy Act 1971—one of the older abortion laws in the world—also became one of the more progressive.

India’s abortion rate, at 47 per 1000 women …

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Abortion law, policy and services in India: a critical review

Affiliation.

• 1 Vadu Rural Health Programme, KEM Hospital, Pune, India. [email protected]
• PMID: 15938164
• DOI: 10.1016/s0968-8080(04)24017-4

Despite 30 years of liberal legislation, the majority of women in India still lack access to safe abortion care. This paper critically reviews the history of abortion law and policy in India since the 1960s and research on abortion service delivery. Amendments in 2002 and 2003 to the 1971 Medical Termination of Pregnancy Act, including devolution of regulation of abortion services to the district level, punitive measures to deter provision of unsafe abortions, rationalisation of physical requirements for facilities to provide early abortion, and approval of medical abortion, have all aimed to expand safe services. Proposed amendments to the MTP Act to prevent sex-selective abortions would have been unethical and violated confidentiality, and were not taken forward. Continuing problems include poor regulation of both public and private sector services, a physician-only policy that excludes mid-level providers and low registration of rural compared to urban clinics; all restrict access. Poor awareness of the law, unnecessary spousal consent requirements, contraceptive targets linked to abortion, and informal and high fees also serve as barriers. Training more providers, simplifying registration procedures, de-linking clinic and provider approval, and linking policy with up-to-date technology, research and good clinical practice are some immediate measures needed to improve women's access to safe abortion care.

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eFigure. Examples of spontaneous abortion cases and ongoing pregnancy controls categorized across 4-week surveillance periods

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Kharbanda EO , Haapala J , DeSilva M, et al. Spontaneous Abortion Following COVID-19 Vaccination During Pregnancy. JAMA. 2021;326(16):1629–1631. doi:10.1001/jama.2021.15494

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Spontaneous Abortion Following COVID-19 Vaccination During Pregnancy

• 1 HealthPartners Institute, Minneapolis, Minnesota
• 2 Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
• 3 Obstetrics and Gynecology, Yale University, New Haven, Connecticut
• Viewpoint COVID-19 Vaccination in Pregnant and Lactating Women Emily H. Adhikari, MD; Catherine Y. Spong, MD JAMA
• Viewpoint Involving Pregnant Individuals in Clinical Research on COVID-19 Vaccines Diana W. Bianchi, MD; Lisa Kaeser, JD; Alison N. Cernich, PhD JAMA
• JAMA Insights Caring for Pregnant and Postpartum Women During the COVID-19 Pandemic Sonja A. Rasmussen, MD, MS; Denise J. Jamieson, MD, MPH JAMA
• Original Investigation Immunogenicity of COVID-19 mRNA Vaccines in Pregnant and Lactating Women Ai-ris Y. Collier, MD; Katherine McMahan, MS; Jingyou Yu, PhD; Lisa H. Tostanoski, PhD; Ricardo Aguayo, BS; Jessica Ansel, NP; Abishek Chandrashekar, MS; Shivani Patel, BA; Esther Apraku Bondzie, BA; Daniel Sellers, BS; Julia Barrett, BS; Owen Sanborn, BS; Huahua Wan, MS; Aiquan Chang, BA; Tochi Anioke, BS; Joseph Nkolola, PhD; Connor Bradshaw, BS; Catherine Jacob-Dolan, BS; Jared Feldman, BS; Makda Gebre, MSc; Erica N. Borducchi, PhD; Jinyan Liu, PhD; Aaron G. Schmidt, PhD; Todd Suscovich, PhD; Caitlyn Linde, PhD; Galit Alter, PhD; Michele R. Hacker, ScD; Dan H. Barouch, MD, PhD JAMA
• Correction Transposed Column Heads in Table JAMA

COVID-19 infection during pregnancy can be associated with severe maternal morbidity. 1 In the United States, 1 COVID-19 vaccine has been approved and 2 have been authorized for use for pregnant women. To date, data on maternal COVID-19 vaccine safety come primarily from passive surveillance, and studies lack an unvaccinated comparison group. 2 , 3 Spontaneous abortion has been identified as a priority outcome in studies of maternal vaccine safety, 4 and concerns regarding risks of spontaneous abortion may be a barrier to vaccination during pregnancy. We present findings from case-control surveillance of COVID-19 vaccination during pregnancy and spontaneous abortion.

The Vaccine Safety Datalink is a collaboration between the Centers for Disease Control and Prevention and 9 health systems, representing approximately 3% of the US population. 5 We applied a validated pregnancy algorithm, which incorporates diagnostic and procedure codes and electronic health record (EHR) data, to identify and assign gestational ages for spontaneous abortions and ongoing pregnancies. 6 Data from 8 health systems (Kaiser Permanente: Washington, Northwest, Northern California, Southern California, and Colorado; Denver Health; HealthPartners; and Marshfield Clinic, Wisconsin) over seven 4-week surveillance periods from December 15, 2020, through June 28, 2021, were included. Ongoing pregnancies between 6 and 19 weeks’ gestation were identified on the last day of each 4-week surveillance period (index date) and contributed data to 1 or more surveillance periods. Spontaneous abortions were assigned to a 4-week surveillance period based on their outcome date; these spontaneous abortions could have been included in the ongoing pregnancy categories during prior periods (eFigure in the Supplement ). Vaccination data came from EHRs, medical and pharmacy claims, and regional or state immunization information systems.

We analyzed the odds of receiving a COVID-19 vaccine in the 28 days prior to spontaneous abortion compared with the odds of receiving a COVID-19 vaccine in the 28 days prior to index dates for ongoing pregnancies. Both spontaneous abortions and ongoing pregnancies were assigned to gestational age groups (6-8, 9-13, and 14-19 weeks), surveillance periods, site, maternal age groups (16-24, 25-34, and 35-49 years), number of antenatal visits (≤1 or ≥2), and race and ethnicity. Generalized estimating equations with binomial distribution and logit link were used to account for repeated ongoing pregnancies across surveillance periods. Analyses by manufacturer and gestational age group were also conducted. Analysis was performed using SAS/STAT software version 9.4 (SAS Institute Inc).

This surveillance was approved by the institutional review boards of all participating sites with a waiver of informed consent.

Of 105 446 unique pregnancies, 13 160 spontaneous abortions and 92 286 ongoing pregnancies were identified. Overall, 7.8% of women received 1 or more BNT162b2 (Pfizer-BioNTech) vaccines; 6.0% received 1 or more mRNA-1273 (Moderna) vaccines; and 0.5% received an Ad26.COV.2.S (Janssen) vaccine during pregnancy and before 20 weeks’ gestation. The proportion of women aged 35 through 49 years with spontaneous abortions was higher (38.7%) than with ongoing pregnancies (22.3%). A COVID-19 vaccine was received within 28 days prior to an index date among 8.0% of ongoing pregnancy periods vs 8.6% of spontaneous abortions ( Table 1 ). Spontaneous abortions did not have an increased odds of exposure to a COVID-19 vaccination in the prior 28 days compared with ongoing pregnancies (adjusted odds ratio, 1.02; 95% CI, 0.96-1.08). Results were consistent for mRNA-1273 and BNT162b2 and by gestational age group ( Table 2 ).

Among women with spontaneous abortions, the odds of COVID-19 vaccine exposure were not increased in the prior 28 days compared with women with ongoing pregnancies. Strengths of this surveillance include the availability of a multisite diverse population with robust data capture. Several limitations should be noted. First, gestational age of spontaneous abortions and ongoing pregnancies were not chart confirmed; pregnancy dating may be inaccurate early in pregnancy. Second, although vaccination status was identified using multiple data sources, the COVID-19 vaccine rollout has been complex and some vaccines may have been missed, potentially biasing findings to the null. Third, data on important confounders, such as prior pregnancy history, were not available. Fourth, it was not possible to assess risks specific to the Ad26.COV.2.S vaccine given the small number of exposures. Despite limitations, these data can be used to inform vaccine recommendations and to counsel patients.

Corresponding Author: Elyse O. Kharbanda, MD, MPH, HealthPartners Institute, 8170 33rd Ave S, Mail Stop 23301A, Minneapolis, MN 55408 ( [email protected] ).

Accepted for Publication: August 26, 2021.

Published Online: September 8, 2021. doi:10.1001/jama.2021.15494

Correction: This article was corrected on September 10, 2021, to reverse the transposed column heads in Table 1.

Author Contributions: Drs Kharbanda and Vazquez-Benitez had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kharbanda, DeSilva, Vazquez-Benitez, Lipkind.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kharbanda, Vazquez-Benitez, Lipkind.

Critical revision of the manuscript for important intellectual content: Haapala, DeSilva, Vazquez-Benitez, Vesco, Naleway, Lipkind.

Statistical analysis: Haapala, Vazquez-Benitez.

Obtained funding: Kharbanda.

Supervision: Kharbanda, Lipkind

Conflict of Interest Disclosures: Dr Lipkind reported serving on the Pfizer independent external data monitoring committee for the COVID-19 vaccine. Dr Naleway reported receiving research funding from Pfizer for an unrelated study. Dr Vesco reported receiving research funding from Pfizer for an unrelated study. No other disclosures were reported.

Funding/Support: This study was funded by contract 200-2012-53526 from the Centers for Disease Control and Prevention (CDC).

Role of the Funder/Sponsor: The CDC participated in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Mention of a product or company name is for identification purposes only and does not constitute endorsement by the CDC.

Additional Contributions: From the Vaccine Safety Datalink: We thank Nicola Klein, MD, PhD (Kaiser Permanente Northern California), Matthew Daley, MD (Kaiser Permanente Colorado), Darios Getahun, MD (Kaiser Permanente Southern California), Stephanie Irving, MPH (Kaiser Permanente Northwest), Michael Jackson, PhD (Kaiser Permanente Washington), Joshua Williams, MD, Simon Hambidge, MD, PhD (Denver Health), James Donahue, DVM, PhD (Marshfield Clinic), and Candace Fuller, PhD (Harvard Pilgrim) for providing subject matter expertise, technical assistance, assistance with data collection, and review of the study. We thank Leslie Kuckler, MPH, and Jingyi Zhu, PhD (HealthPartners Institute) for their assistance with data collection. We also thank Eric Weintraub (CDC) and Brad Crane (Kaiser Permanente Northwest) for assistance with data collection and management in addition to administrative and technical support. All persons acknowledged have been compensated by the CDC.

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Safe abortion saves lives

In practice, women have long been struggling to access safe abortions, even when they have the right to terminate the pregnancy.

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he government just enacted a new rule that makes it easier for women to get safe abortions in cases of rape or medical emergency. This is part of a larger health reform that was introduced last year to improve women's reproductive health and reduce maternal deaths.

The regulation requires certain large clinics and hospitals to provide medical assistance before and after abortion for rape survivors with a gestational age up to 14 weeks, and women with life-threatening medical conditions or if the fetus has lethal anomalies.

The regulation has been welcomed by women's and human rights groups, but they have also criticized a requirement for rape survivors to obtain a statement from the police attesting that their pregnancy resulted from rape or sexual violence.

The big question now is whether the police will actually implement the policy and whether there are enough hospitals in the country that can provide safe abortion services.

Abortion is illegal in Indonesia, except in cases of rape, where the pregnancy is no longer than 14 weeks old, or if the woman has a life-threatening medical condition or if the fetus has lethal anomalies, according to the latest health law and the Criminal Code. Previously, the cutoff gestational age in cases of rape was six weeks.

But in practice, women have long been struggling to access safe abortions, even when they have the right to terminate the pregnancy.

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A case from 2021 involving a 12-year-old rape survivor in Jombang, East Java, is a case in point. The girl was turned away by the police when she asked for a safe abortion, even though she was eligible for one under the previous law.

In a Muslim-majority country like Indonesia, where terminating pregnancies is still a touchy subject, the lack of information about safe abortion and the victim-centered approach of the authorities are often seen as reasons why rape victims do not seek the help they need.

The National Commission on Violence Against Women (Komnas Perempuan) reports that 103 cases of rape-related pregnancy were reported between 2018 and 2023. Unfortunately, almost all of these women were unable to access safe abortions.

It is worth asking whether rape victims will turn to the police for help, given that the force has yet to issue any internal regulations about specific assistance for the victims, including safe abortion services, as well as special training for officers.

Furthermore, in a patriarchal society, unsafe abortion is more likely to happen. Male babies are preferred as they are believed to bring wealth and prosperity to the family while girls are often seen as a burden.

UNICEF data in 2006 found that 10 million girls have been killed by their parents since 1986, both before and during childbirth, in India. It is likely to be a similar case for Indonesia.

Data from the Health Ministry show that the maternal mortality rate hit 183 per 100,000 births in 2022. Of that number, an estimated 11 percent resulted from unsafe abortions.

Actually, there is very little research on abortion in Indonesia, let alone on abortion-related deaths. Nevertheless, the United States-based Guttmacher Institute, a pro-choice research group, estimated 43 abortions per 1,000 women of reproductive age between 15 and 49 took place in 2018 in Java, where almost 57 percent of the Indonesian population lives. The figure was higher than the rate for Southeast Asia, which stands at 34 abortions per 1,000 women.

It is crucial to make safe abortion services available to reduce one of Southeast Asia's highest rates of maternal deaths. Indonesia has a much higher maternal mortality ratio than other countries in the region.

Safe abortion has saved many lives. At the very least, it protects the rights of women who are victims of sexual violence.

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Do Abortion Bans Affect Reproductive and Infant Health? Evidence from Texas's 2021 Ban and its Impact on Health Disparities

Political Economy Research Institute Working Paper No. 606

107 Pages Posted: 6 Aug 2024

Raymond Caraher

University of Massachusetts Amherst

Date Written: July 30, 2024

The overturning of Roe v. Wade led to a wave of abortion bans in state legislatures across the United States. This emergence of a restrictive reproductive health policy environment has the potential to affect a wide range of reproductive health outcomes. This paper uses Texas's 2021 6-week ban on abortion as a case study to examine the causal effect of an abortion ban on reproductive health outcomes, specifically abortion rates, fertility rates, and infant health outcomes. It examines how these effects may be heterogeneous by group, especially focusing on how the effects of abortion bans on reproductive health may be concentrated in those who are already facing disparities in reproductive health outcomes such as Black women. Using a difference-indifferences strategy, the analysis finds that the ban decreased abortion rates by over 40 percent, and increased fertility rates by about 4 percent, with the largest increases for Black non-Hispanic women and for counties far from a state with less restrictive abortion laws. This paper then constructs a measure of unmet reproductive health needs after an abortion ban, and finds that the unmet needs after the Texas 6-week ban are largest in counties with higher proportions of Black non-Hispanic residents, as well as counties which are furthest away from states which did not ban abortion after the Dobbs decision. The analysis then examines the effect of the ban on infant health outcomes, specifically focusing on heterogeneity in the effect of the ban on birth weight and infant mortality. This paper finds that the ban led to increases in the probability of an infant being born with very low birth weight of about 7 percent, with Black non-Hispanic infants experiencing the largest increases in the likelihood of very low birth weight. Additionally, the analysis finds significant increases in the infant mortality rate of about 6 percent after the abortion ban, again with Black non-Hispanic infants experiencing the largest increases in mortality. Further, the ban increased infant mortality rates more in counties which are further away from states which did not ban abortion after the Dobbs decision. The results suggest that the effects of abortion bans tend to be especially concentrated in marginalized populations, as well as those who are least able to shift their fertility options away from in-state abortions after a ban. The analysis shows that the trend towards an increasing number abortion bans will further exacerbate disparities in reproductive health outcomes.

Keywords: Reproductive Health, Abortion, Fertility, Infant Health, Abortion Ban, Texas

JEL Classification: I18, J13, K32

Suggested Citation: Suggested Citation

Raymond Caraher (Contact Author)

University of massachusetts amherst ( email ).

Amherst, MA 01003 United States

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Where is the most religious place in the world?

Over the last decade and a half, Pew Research Center has conducted religion-focused surveys all around the world. One question we have asked in each of these surveys is “How important is religion in your life?” Another one we’ve asked repeatedly is “How often do you pray?”

Using these questions, we see a broadly similar pattern across the 102 countries and territories we surveyed between 2008 and 2023. The places that are most religious by these two measures tend to be in sub-Saharan Africa, Latin America and the Middle East-North Africa region. The places that are least religious tend to be in Europe and East Asia.

Of course, there are dimensions of spirituality that these two survey questions don’t pick up, as we’ve explored in regional surveys . At the end of this analysis, we discuss how we could incorporate new measures in the future .

Pew Research Center conducted this analysis to look back at the religion-focused survey research we’ve done around the world for the last decade and a half. The analysis also describes some of our future plans for measuring spirituality and religiosity around the world.

This analysis is primarily based on our recent report, Religion and Spirituality in East Asian Societies. For that report, we surveyed 10,390 adults across East Asia and neighboring Vietnam. Local interviewers administered the survey in seven languages from June to September 2023.

Interviews were conducted over the phone in four places: Hong Kong, Japan, South Korea and Taiwan. In Vietnam, interviews took place face-to-face.

Respondents were selected using a probability-based sample design. Data was weighted to account for different probabilities of selection and to align with demographic benchmarks for the adult population.

For more information, refer to the report’s Methodology and the full survey questionnaire .

This survey is part of the Pew-Templeton Global Religious Futures project , which analyzes religious change and its impact on societies around the world.

Data for the nearly 100 other countries and territories in this analysis comes from previous religion-focused surveys conducted between 2008 and 2023: sub-Saharan Africa ; the Middle East-North Africa region and many countries with large Muslim populations ; Latin America ; Israel ; Central and Eastern Europe ; Western Europe ; India ; South and Southeast Asia ; and the United States . Additional information on these previous surveys can be found in the report’s appendix .

Importance of religion around the world

People in sub-Saharan Africa are typically among the most likely to say that religion is very important in their lives. At least 90% of adults say this in Senegal, Mali, Tanzania, Guinea-Bissau, Rwanda and Zambia.

In contrast, people in nearly all European countries surveyed are among the least likely to say that religion is very important in their lives. In Estonia, the Czech Republic, Denmark, Switzerland, the United Kingdom, Sweden, Latvia and Finland, 10% or fewer adults say this.

The pattern in South and Southeast Asia is not as consistent as in sub-Saharan Africa and Europe. Adults in some places in this region are among the most likely worldwide to place a great deal of importance on religion. Consider Indonesia, for example, where nearly all adults say religion is very important in their lives. But far smaller shares in Singapore (36%) and Vietnam (26%) give this answer.

In the United States, 42% of adults say religion is very important in their lives. This is below the 102-place median of 55%.

Rates of daily prayer around the world

Latin Americans are among the most likely in the world to say they pray daily. In both Guatemala and Paraguay, 82% of adults say this, as do 78% in Costa Rica and Honduras.

Meanwhile, in no place surveyed in East Asia do more than 21% of adults say they pray daily. This includes 13% of people in Hong Kong and 19% in Japan.

Adults in the U.S. are in the middle of the 102 countries and territories analyzed when it comes to rates of daily prayer. Some 45% of Americans say they pray daily, which is nearly identical to the 102-place median of 46%.

The complexities of measuring religiosity globally

Asking people about the importance of religion in their lives and how often they pray can provide an important window into their religiosity. But these questions work better in some places than in others.

These two measures may be especially valuable in places where Abrahamic religions – Judaism, Christianity and Islam – predominate, because prayer and formal religious organizations are central to those traditions. In other parts of the world, we need to ask additional questions to capture key aspects of religious or spiritual observance.

A prime example is our 2023 survey of East Asian societies and neighboring Vietnam . Before this survey, we consulted with experts from the region to devise questions that would tap into the most relevant aspects of spirituality. We also conducted qualitative research in Japan and Taiwan to ensure we were taking the right approach.

The survey found that while few East Asians consider religion very important in their lives or pray daily, many people across the region hold religious or spiritual beliefs and engage in traditional rituals. For example, many East Asians participate in rituals to honor their ancestors .

We also asked tailored, culturally relevant questions in our 2019-20 survey of nearly 30,000 adults in India . For example, that survey found widespread adherence to dietary choices related to religion . We found that 92% of Jains are vegetarian, and 67% of India’s Jains also abstain from eating root vegetables. Among all Indian adults, only about half said they would ever eat in the home of someone whose religion has different rules about food.

How we plan to measure religiosity and spirituality around the world in the future

Our recent survey of East Asia and Vietnam largely marks the end of our customized, region-by-region surveys of religiosity and spirituality. But this does not mean we are done researching religion around the world.

Building on what we’ve learned, we now plan to conduct surveys in 30 or more countries at the same time. By simultaneously surveying countries in Asia, Africa, Europe and the Americas, we can gain a comparative understanding of spirituality around the world.

As we survey the same countries over time, we can also repeat some questions to see how different parts of the world are – or aren’t – changing religiously.

This new approach will allow us to ask questions around the world that were originally designed for a specific region. For example, based on our work in East Asia, we plan to ask respondents across the globe whether they think various parts of nature have their own spirits . We recently asked questions like these in the U.S. and found that 48% of American adults believe that mountains, rivers or trees can have spirits or spiritual energies. This is similar to the share of adults in Japan and Vietnam who believe in such spirits.

Using measures from a variety of cultures and religious traditions will help us move toward a richer understanding of people’s spiritual lives.

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Jonathan Evans is a senior researcher focusing on religion research at Pew Research Center .

Rituals honoring deceased ancestors vary widely in East and Southeast Asia

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Supreme Court of India judgement on abortion as a fundamental right: breaking new ground

Dipika jain.

Professor of Law; Vice Dean Research & Clinical Legal Education; Director, Centre for Justice, Law and Society, Jindal Global Law School, O.P. Jindal Global University, Sonipat, India.

The Supreme Court of India’s judgement on 29th September, 2022, held that unmarried women have the same right to abortion as married women. The Medical Termination of Pregnancy Act, 1971 (MTP Act), 1 most recently amended in 2021 (Amendment Act), 2 governs the circumstances under which abortions are legally permitted in India. The law is an exception to criminalisation of abortion under the Indian Penal Code (IPC). The Amendment Act of 2021 is a substantially yet inadequately reformed version of the original MTP Act, including an extension of the gestational limit from 20 to 24 weeks for “certain categories of women”. These are listed under Rule 3B of the MTP Rules, 2021 3 notified under the MTP Amendment Act, and include survivors of rape, incest, minors, women experiencing a change of marital status (widowhood or divorce), women with disabilities, women with fetal anomaly and those living in emergency, disaster, or humanitarian crises. Notably, the Amendment Act expanded the contours of access by replacing the term “married women” under the 1971 law, with “any woman”, allowing pregnant persons to seek abortions, irrespective of their marital status. However, by restricting termination between 20 to 24 weeks of gestation to “certain categories of women” delineated under Rule 3B, the benefits of the Act do not extend to unmarried women, unless they fall under any of the other categories listed under Rule 3B. Further, the Amendment Act allows termination of pregnancies beyond 24 weeks only in cases of fetal anomalies. The revised law thus exceptionalises persons with disabilities and retains the eugenic rationale of the original MTP Act. 4 The provisions of the Act are not framed in a gender justice context, taking note of the rights of pregnant persons. The Amendment Act still requires the permission of doctors for abortions to take place, making it a doctor-centric legislation, and does not take into account doctors’ hesitation to grant abortions for fear of prosecution under the IPC or conflations with the Protection of Children from Sexual Offences Act, 2012 (POCSO Act) and other laws. 5

In X v. the Principal Secretary Health and Family Welfare Department & Another 6 decided by a three-judge bench of the Supreme Court, the anonymous Petitioner learned that she was pregnant in June 2022. On 5 July 2022, an ultrasound revealed an intrauterine pregnancy of 22 weeks. She moved a petition before the High Court of Delhi with a request to terminate her pregnancy through registered medical practitioners (RMPs) at a private or government centre or hospital before 15 July 2022, during the statutory limit of 24 weeks. One of her prayers to the Court was to include unmarried women within the scope of Section 3(2)(b) which governs the termination of pregnancies between 20 to 24 weeks of gestation. The High Court held that since the Petitioner is an unmarried woman whose pregnancy arose out of a consensual relationship, her case is “clearly not covered” by clauses of Rule 3B of the MTP Rules. As a consequence, her termination request was denied. A Special Leave Petition was then filed before the Supreme Court, which found that the principle of statutory interpretation is that the words of a statute must be read in their entire context.

The Supreme Court while delivering a landmark judgement emphasised that in a gender-equal society, it is imperative that interpretation of the MTP Act and Rules consider current social realities. Speaking for the bench, Justice Chandrachud noted, “ A changed social context demands a readjustment of our laws. Law must not remain static and its interpretation should keep in mind the changing social context and advance the cause of social justice ”. This judgement and the recent Amendment Act together significantly expanded the scope of abortion rights in India. The most important changes to the law are explained below:

First, the Court held that every pregnant person in India has a right to reproductive decisional autonomy, including transgender and gender-variant persons. Everyone is entitled to reproductive health, including access to safe, effective, and affordable methods of family planning, access to contraception, and sex education. Further, the Court acknowledged that the MTP Act is a provider-centric law that does not focus on the rights of pregnant persons. Since the right to access abortion depends on approval from a RMP, denial of services compels women to approach courts or seek abortion in unsafe conditions. RMPs are reluctant to provide abortion services due to fear of prosecution under the IPC, which has a chilling effect on the behaviour of healthcare service providers. Therefore, the Court held that the decision to terminate a pregnancy vests solely with the pregnant person.

Second, the Court expanded the scope of access to abortion services from 20 to 24 weeks, taking note of the factors and circumstances changing the material realities of women and how individuals’ unique circumstances cannot be exhaustively accounted for by the law. The Court held,

“the decision to give birth to and raise a child is formed by one’s material circumstances, which includes the situational, social and financial circumstances of a woman and her family and each of these is relevant to her decision to carry the pregnancy to term”.

The Court noted that individual circumstances should be considered on a case-to-case basis because it is not possible for the “ legislature or the Court to enlist each of the potential events which would qualify as a change of material circumstances ”. The Court held that it is ultimately the prerogative of pregnant persons to make decisions, keeping in mind their material circumstances.

Third, the Court clarified that rape as grounds for abortion includes marital rape. The Court noted, “ It is not inconceivable that married women become pregnant as a result of their husbands having ‘raped’ them.” It is important to clarify that the Court noted that rape should include marital rape for the purpose of the MTP Act, and that reading the provisions of the MTP Act in a manner that excludes married women who may be pregnant as a result of forced or abusive sexual conduct of their husbands would compel them to have children with abusive partners.

Fourth, the Court empathetically noted that the MTP is a beneficial legislation meant to enable access to abortion services for all pregnant persons. Therefore, the RMPs should offer abortion services without any extra-legal conditions like spousal or family consent, documentation requirement or judicial authorisation.

Further, a significant part of the judgement is the observations on adolescent access to abortion. The Protection of Child from Sexual Offences (POCSO) Act, 2012 was enacted to address issues of child sexual abuse, sexual harassment and child pornography. It criminalises all sexual conduct involving a “child”, who is defined as a person not having attained 18 years of age. The Act also has provisions on mandatory reporting of any sexual activity involving a “child” under Section 19, meaning that when an adolescent seeks abortion services, the RMP is obligated to report an offence of statutory rape under the Act. Taking note of how mandatory reporting requirements impede access to abortions for adolescents, the Court harmoniously read the MTP with POCSO and held that medical practitioners do not need to disclose the identity and personal details of an adolescent seeking an abortion, when filing their report under Section 19 of the POCSO Act. It emphasised that “it could not possibly be the legislature’s intent to deprive minors of safe abortions”.

The decision of the Supreme Court is a landmark ruling on issues of access to abortion and the right to reproductive and decisional autonomy. The Court relied on earlier decisions to articulate a right to reproductive autonomy as a manifestation of the right to decisional autonomy extending to one’s sexual and reproductive health, which are integral parts of right to privacy, self-determination and right to dignity under articles 14 and 21 of the Constitution of India.

Most significantly, the court recognised several structural barriers that adversely impact access to abortion services including lack of access to health services, caste discrimination, bureaucracy, and poverty, among others. Therefore, the Court issued directions to the Government to ensure that all pregnant persons are able to access abortion and contraception services, information regarding reproduction and safe sexual practices, and that medical facilities and RMPs must be available in every district to provide services to all pregnant persons including marginalised persons with sensitivity and care. The Court noted that unless these recommendations are implemented the right to reproductive and bodily autonomy cannot be achieved.

Many of the concerns articulated by SRHR activists regarding the Amendment Act have been addressed by this judgement. Justice Chandrachud observed that reproduction is both biological and political, and (the) “ decision is intimately linked to wider political, social, and economic structures. A woman’s role and status in family, and society generally, is often tied to childbearing and ensuring the continuation of successive generations”. The abortion law, while being touted as a legal framework that protects pregnant persons’ rights, was not a rights-based legislation. The right to access safe abortions at will remained aspirational for the majority of pregnant persons in India. This landmark, historic decision paves way for abortion on demand creating a pregnant person’s right in India.

Further, criminalisation of abortion is acknowledged by Justice Chandrachud to impede access. As we move forward, decriminalising abortion will reverse the “chilling effect” on RMPs, making it more likely that they will grant abortions, rather than involving courts. And most importantly, the decision to terminate an unwanted pregnancy now vests only with the pregnant person in India, making it a rights-based legal framework. The MTP Act must therefore be read and implemented accordingly. However, in order for the impact of this verdict to translate on the ground, the legislative framework must be amended to remove the ambiguities and other barriers taken note of by the Court.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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Where Tim Walz Stands on the Issues

As governor of Minnesota, he has enacted policies to secure abortion protections, provide free meals for schoolchildren, allow recreational marijuana and set renewable energy goals.

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By Maggie Astor

• Aug. 6, 2024

Gov. Tim Walz of Minnesota, the newly announced running mate to Vice President Kamala Harris, has worked with his state’s Democratic-controlled Legislature to enact an ambitious agenda of liberal policies: free college tuition for low-income students, free meals for schoolchildren, legal recreational marijuana and protections for transgender people.

“You don’t win elections to bank political capital,” Mr. Walz wrote last year about his approach to governing. “You win elections to burn political capital and improve lives.”

Republicans have slammed these policies as big-government liberalism and accused Mr. Walz of taking a hard left turn since he represented a politically divided district in Congress years ago.

Here is an overview of where Mr. Walz stands on some key issues.

Mr. Walz signed a bill last year that guaranteed Minnesotans a “fundamental right to make autonomous decisions” about reproductive health care on issues such as abortion, contraception and fertility treatments.

Abortion was already protected by a Minnesota Supreme Court decision, but the new law guarded against a future court reversing that precedent as the U.S. Supreme Court did with Roe v. Wade, and Mr. Walz said this year that he was also open to an amendment to the state’s Constitution that would codify abortion rights.

Another bill he signed legally shields patients, and their medical providers, if they receive an abortion in Minnesota after traveling from a state where abortion is banned.

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