6. UNSAFE ABORTIONS Complications from unsafe abortions if untreated, could lead to morbidity or death. The best way to prevent unsafe abortions is to reduce the unmet need for contraception and make safe abortion services accessible to women at an affordable cost. Post abortion counseling and follow up for contraception and morbidity reduction needs to be strengthened. The institute focuses its research activities on the study of women s knowledge, attitude and practice regarding abortions and to investigate abortion seeking behavior related to unwanted pregnancies and improving medical methods for termination of first and second trimester pregnancy. 6.1 Contraceptive Knowledge and Practices of Women Requesting Medical Termination of Pregnancy Principal Investigator: Project Associates: Collaborator: Lalita S. Savardekar Duration: 1999 2003 Shalini Baji, Rashmi Shah, U. Iddya and D. Balaiah Vandana Walvekar Nowrosjee Wadia Maternity Hospital, Mumbai Modern and effective methods of Family Planning (FP) are easily available in Mumbai, yet the need for abortion still exists. To address this research issue, 740 women seeking abortion at an urban hospital Nowrosjee Wadia Maternity Hospital, Mumbai were interviewed to study the contraceptive knowledge, attitude and practices of women requesting medical termination of pregnancy (MTP) and to identify the determinants of unwanted or mistimed pregnancy. Data was analysed from 700-filled questionnaires and 40 were discarded due to reluctance/incomplete information given by women. Details of the subject characteristics, type of family planning methods currently used, reasons for nonuse and failure of the methods have been previously reported (Annual Report 2001-02, p 79). As regards the outcome of the last pregnancy, majority of the women had a normal delivery while a few of them had a successive induced abortion (Fig. 106). 170
13% 4% 1% No pregnancy FTND Spontaneous Abortion Induced Abortion Fig. 106: Outcome of last delivery among abortion seekers 82% Despite experiencing an induced abortion in the last pregnancy, one third women came for a repeat abortion within one year (Table 13). In spite of experiencing an induced abortion in the last pregnancy, 24 women (26.3%) did not use any family planning method while the methods frequently used were withdrawal (29.7%), condom (16.5%) rhythm (4.4%) alone or in combination (10%). The other methods were oral pills (6.7%), Intra Uterine Contraceptive Device (IUD) (1%), tubal ligation (1%) and vaginal cleaning (4.4%). To prevent unplanned pregnancy majority of the women who had incomplete knowledge of Cu-T or oral pills, relied on methods like withdrawal, rhythm that have no ill health effects and hence did not opt for modern effective methods. Table 13: Consecutive induced abortion and use of family planning methods Time interval between previous abortion to current pregnancy (months) Used F.P. method (n = 67) 171 Not used any F.P. method (n=24) Total women having consecutive abortions (n = 91) 0 6 7 3 10 7 12 12 9 21 13 18 3 1 4 19 24 10 3 13 >24 35 8 43 In addition to these 91 women, 59 women had experienced a surgical abortion in the past. In summary, a total of 150 women (21.4%) had undergone surgical abortion in the past either one or more than one time. Hypothesizing that these women would have been counseled to use modern methods prior to or after MTP, yet over 75% reported the use of methods like withdrawal, condom or no method (Fig.107) to prevent the current pregnancy.
40 35 35.6 IUD CoCs Condoms 30 26.9 Spermicide 25 21.8 22.9 22.7 Rhythm 20 18.4 Withdrawal 15 10 5 0 12 11 6 4.7 4.8 2.9 3.1 3.3 2.2 1.3 0 0.2 0.1 0 0 0.1 1st Abortion (N = 550) > 1 Abortion (N = 150) LAM Tubal ligation Vaginal cleaning W/C/R No method Fig. 107: Family planning methods used by women undergoing abortion first time and more than one time Though these women had experienced surgical abortion, the awareness of the side effects and complications of MTP ranged from 11 to 56 per cent. Women requesting for an abortion for the first time were poorly informed (range 3 to 19%) (Fig. 108). 60 56 50 40 30 20 10 0 46 34 30.7 28.7 29.3 25.3 19.5 17.3 11.3 7.1 8.8 7.3 10 8.9 3.1 1st Abortion (N = 550) > 1 Abortion (N = 150) Bleeding Pain Infection Incomplete abortion Uterine perforation Organ Injury Infertility Mortality Fig. 108: Awareness of MTP related side effects among women undergoing abortions first time and more that one time It seems reasonable to believe that with incomplete knowledge of the surgical abortion and the past experience of induced abortion, women viewed MTP as a easy and safe solution to prevent unwanted pregnancy. Women were questioned regarding their willingness to use FP methods after abortion, type of methods and reasons for accepting the same. Women expressed their willingness to use tubal ligation (47.2%), IUD (34.9%) more often in 172
comparison to oral pills (7.2%) or condom (4.6%) while a few were still comfortable with only withdrawal or vaginal cleaning (Table 14). Table 14: Willingness of women to use family planning method after abortion Type of method Willingness (N= 700) % IUD 34.9 COC 7.2 Condom 4.6 Spermicide 0 Rhythm 0 Withdrawal 0.4 Injection 0.7 Tubal ligation 47.2 Vasectomy 0.4 Vaginal cleaning 1.7 Dual methods 2.9 Though women were not mentally prepared to accept IUD, they voiced their willingness to use it because they felt that the abortion would not be done unless they accept IUD as a FP measure. A choice for oral pills or condom was made as they viewed it as an easy method, no ill health, effects, fear /experience of Cu T side effects. The information obtained from these open-ended questions stress the need to increase and impart correct knowledge regarding IUD among women so that they accept it by choice and not as a hospital policy. (Table 15) This would help in improving acceptance and continuation of IUD a safe, cheap and effective FP method. 173
Table 15: Willingness to use FP method after abortion: Reasons Reasons IUD N=230 % CoC N=50 % Condom N=32 % Tubal Ligation N=330 % Completed family 0 0 0 84.8 No ill health effects 1.3 6.0 34.4 0 One time method 34.4 0 0 14.9 Easy 0 10.0 3.1 0.3 Hospital policy 31.3 4.0 0 0 Relative counseled 3.4 6.0 0 0 Fear of Copper T 0 44.0 31.3 0 Bad experience of Copper T 0 14.0 3.1 0 Least chance of failure 13.9 2.0 0 0 Only suitable method 10.4 2.0 9.4 0 Doctor counseled 1.9 4.0 0 0 Husband s decision 1.3 6.0 12.5 0 Against religion 2.1 2.0 0 0 Copper T examination not feasible 0 0 6.2 0 In conclusion, the study results reflect that women still have incorrect /incomplete knowledge about modern effective methods like IUD or oral pills which is a major hindrance in initiating and continued use of these methods. Being unaware of the failure rate of methods like withdrawal or condom methods with no health risks, women continue using these methods to prevent unplanned pregnancy. IEC needs to be intensified at both, the provider and client level. Also, complete information needs to be imparted to the eligible couples for an increased and sustained use of effective methods. 174
6.2 Strategies to prevent unsafe abortions 6.2.1 A Double Blind Randomized Comparison of Two Misoprostol Regimens for Termination of Pregnancy in the Second Trimester (WHO Multicentre Study) Principal Investigator: Project Associates: Collaborator: Rashmi Shah Duration: 2002-2004 Anita Peddawad, Kavita Tilwani, Bhagyashree Kanje and Ruhi Pednekar Rekha Daver, J.J. Group of Hospitals, Mumbai This is a prospective double blind placebo controlled trial comparing vaginal and sublingual regimens of misoprostol in the termination of pregnancies of 13-20 weeks duration. A total of 40 women were enrolled for the study excluding 2 regimens that were used as quality control. The women were allocated randomly to receive the active drug i.e. 0.4 mg misoprostol administered either vaginally or sublingually every 3 hours up to five doses. In the event the abortion did not occur, the regimen was repeated. The side effects were recorded 3-hourly during the stay at the hospital and the outcome assessed 24 hours (and 48 hours, if needed) after the initiation of the treatment. Fifty percent of women aborted within 10 hours of initiating the treatment. Complete abortion was achieved in 33 women, 5 needed an additional course of sublingual treatment while 2 women experienced method failure hence had to undergo ethacridine / oxytocin instillation. Table 16: Induction abortion interval in women undergoing second trimester abortion Induction abortion interval (in hours) 175 Number of subjects 5 10 20 10 15 9 15 20 2 20 25 2 25 30 3 30 35 1 35 40-40 45 1 Failed method 2 TOTAL 40
The study was initiated in November 2002 and completed in September 2003. The data will be decoded and analysed at Geneva. 6.2.2 Comparison of two routes and two intervals of administration of misoprostol for the termination of early pregnancy: a randomized multicentre trial (WHO Multicentre Study) Principal Investigator: Project Associates: Collaborator: 176 Rashmi Shah Duration: 2002 2004 Anita Peddawad, Kavita Tilwani, Bhagyashree Kanje and Ruhi Pednekar Rekha Daver, J.J. Group of Hospital, Mumbai. The design of the study is randomized, stratified by center and by the length of gestation: <49 days; 50-56 days; 57-63 days. One hundred and eighty eight women were randomly allocated to receive three sublingual or vaginal doses of 0.8mg of misoprostol either at 3-hour or 12-hour intervals. Four regimens served as quality control. The final outcome side effects since treatment was assessed at the follow-up visit on day 15 of the study, unless women were bleeding and required further follow-up. Abortion was successful in 123 women while 49 needed surgical intervention and 7 were lost to follow up. The enrolment has been completed but follow up is awaited in 9 women. 6.2.3 Pretreatment with misoprostol before vacuum aspiration for first trimester induced abortion: a multicentre, double blind randomized controlled trial (WHO Multicentre Study) Principal Investigator: Project Associates: Collaborator: Rashmi Shah Duration: 2002 2004 Lalita Savardekar, Anita Peddawad, Kavita Tilwani, Bhagyashree Kanje, Ruhi Pednekar Rekha Daver, J.J. Group of Hospital, Mumbai. This is a multicentre double blind randomized placebo controlled trial of misoprostol administered 3 hours prior to surgical vacuum aspiration abortion in the first trimester of pregnancy. The objective of the study is to evaluate whether vaginal administration of misoprostol facilitates cervical dilation and reduces complications among women undergoing first trimester induced abortion. The women received either active tablets (400 µg misoprostol) or placebo tablets, which contained only the
vehicle of the misoprostol containing tablets, prior to surgical vacuum aspiration. A total of 188 women have completed the study of the targeted 356 women. Four regimens serve as quality control. The study is ongoing. 177