6. BRIEF RESUME OF THE INTENDED BOOK
INTRODUCTION
You can tell the condition of the nation by looking at the status of its women
Jawaharlal Nehru.
Termination of pregnancy refers to a procedure, whether medical or surgical, that results in expulsion of the products of conception. first trimester termination of pregnancy refers to pregnancies Ended before 12 weeks of gestation Second trimester termination refers to pregnancies ended after 13+0 weeks of gestation.1
Up to 53 million abortion are performed each year WHO 1997 an estimated one third are performed under unsafe condition medical abortion has the potential to be provided in the community by the nursing staff and be lower in cost compares to surgical method.2
Termination of pregnancy offers women greater choice and empowerment .the potionof medical termination of pregnancy gives women more control; reduce the need for anaesthetic and mimeses the risk of infection or trauma to reproductive organs. Termination of pregnancy only takes place with the informed consent of a pregnant woman. In cases of severe mental disability or long-term unconsciousness, the consent of a person other than the pregnant woman is considered (Termination of Pregnancy Act no 92 of 1996).3
The Nation of pregnancy (MTP) cases conducted in clinics recognized by the government (Khan, et al n.d.). These abortion statistics show an increase in MTP since the liberalization of abortion laws in 1988 until the early 1999s (Khan et al. 200 from Family Welfare of India Year Book, Government of India, 2003.4
Termination of pregnancy is a common procedure, estimated to be the outcome of around one in four pregnancies in Australia.2-4 the large majority of terminations occur in the first trimester of pregnancy. It is further estimated that around one third of all Australian women have at least one abortion.5
The United States has the highest rate of teen pregnancy in the Western world. Although abstinence may be the ideal solution for the prevention of this problem, one half of adolescents in the United States are sexually active. This article reviews the epidemiology of oral contraception among adolescents.6
MTP Act and associated rules and regulations to determine how the law can be revised to decentralize abortion services and otherwise better meet the needs of women; upgrading facilities that currently offer MTP services; orienting MTP services to meet the needs of women most at risk of accessing unsafe abortion; increasing awareness among women and men of reproductive age of the availability of safe abortion services and the dangers of unsafe abortion.7
Critics of the abortion law admit that when it was introduced it was a great achievement for women’s health. Nearly 30 years later, the law and associated rules and regulations are considered overly mediatised and bureaucratic and as such not oriented toward women’s right to access safe and legal abortion services. The law offers substantial protection for medical providers. Chhabra and Nuna (1947) note that “doctors receive blanket indemnity under the MTP Act – instead of functioning as for other surgical procedures and taking the consequences of any default or neglect”. Jesani and Iyer (1995) 8
The Shah Committee’s estimates were based on India’s 1966 population of 500 million and crude birth rate of 39 and the assumption of a constant ratio of 15 induced abortions per 73 live births. The committee derived this ratio from community studies in Tamil Nadu and hospital studies in Delhi. Chakra and Nona’s estimates were based on 1991 birth rates and population figures, using the same Shah Committee ratio of abortions to live births and suggested 6.7 million legal and illegal induced abortions take place annually in India (Chhabra and Nuna 1994).9
Bureaucracy associated with registering MTP facilities with the government and with reporting and recording MTP procedures, further contributes to the end result that many physicians provide abortion illegally .When a physician performs abortion without registering the procedure, the physician can avoid the extensive paperwork associated with reporting MTP (Barge et al. 1994; Chhabra and Nuna 1994; Kerrigan et al. 1995)10
The Medical Termination of Pregnancy Act, approved in India in 1971 and enacted in 1972, permits abortion (or MTP) for a broad range of social and medical reasons, including: to save the life of the woman; to preserve physical health; to preserve mental health; to terminate a pregnancy resulting from rape or incest and in cases of fatal impairment. Contraceptive failure also is sufficient ground for legal abortion (United Nations 1993).11
Oral contraceptive is a method of contraception that can be used to prevent unprotected act of sexual intercourse. There are both hormonal and non hormonal methods of contraception are available. These methods also been called morning after pills or post coital contraception. But the term emergency is most suitable as these methods are used by women with a few hours to few days of unprotected intercourse and not just next morning.12
The World Contraceptive Use 2010 contains data on contraceptive prevalence for 193 countries or areas of the world and for 165 countries and areas there are at least two available data points. The latest estimates are as of December 2010.12
Awareness about emergency contraception in India is low. We carried out a survey of 1125 urban and 575 rural women in the reproductive age group. It showed that only 8% of urban women and 3% of rural women knew about Emergency Contraception. We carried out a similar random survey of 342 gynaecologists and found that only 30% had some knowledge about Emergency Contraception Only 54 women (32.1%) presented within 72 hours after intercourse. This is due to lack of awareness. All women coming up to 10 days after coitus were provided with Yuppie method. There were 42 adolescent girls, 28 unmarried women and 98 married women in this study. The large majority of the 54 women who presented within 72 hours were adolescent girls or unmarried women.13
Oral contraceptives, or “the pill,” are tablets taken once a day to prevent pregnancy. The pill has been available since the 1960’s, and since that time, several changes have occurred over time. One major change has been the reduction in the dose of the hormones, estrogens and progesterone.Oral contraceptives also known as birth control pills are used for the prevention of pregnancy .the two female sexare estrogens and progestin. Combined of these two female hormones help prevention of ovulation. Another critical element of abortion care is contraceptive counselling and services. Several studies report that the majority of abortion clients accept contraception after an MTP procedure (Barge et al. 1997; Chhabraet al. 1988).14
6.1 NEED FOR THE STUDY
The Medical Termination of Pregnancy Act of 1971 greatly liberalized the indications for which abortion is legal in India. The Act to reduce the incidence of illegal abortion adolescence and maternal mortality.However, 30 years after the groundbreaking legislation. Studies suggest that the choice of specific provider is most often not made by the woman inducing abortion but with or by her husband or other family members. While the incidence of abortion in India is unknown, the most widely cited figure suggests that around 6.7 million abortions take place annually. According to government of data, only about 1 million abortions take place annually. And only about 1 million of these are perform legal.15
The gap between reported legal abortion and total abortion estimates suggests that less than 10 percent of the abortions that take place in India are conducted legally (Khan et al. n.d.). In the 1983-84 ICMR study, of the 55 percent of abortions conducted in the first trimester, only about25 percent were conducted by certified doctors or other health staff (Indian Council of Medical Research 1988; World Bank 1996).16
Government facilities are acknowledged to be inadequate providers of abortion services. MTP facilities are most often located in urban areas while the vast majority of Indian women live in rural areas. Only about ten percent of the clinics that are registered to. Unfortunately, many government facilities that are supposed to provide MTP services free of charge actually charge clients for MTP services, placing another barrier to women’s access of safe abortion from the formal health care system (Khanetal. 1999; Khan et al. 1998.17
The Kuntz study calculated failure medical termination of the pregnancy to be taken before 7 weeks gestation, compared to 7 to 12 weeks gestation.31 Paul all’s study of 1132 women who had abortions prior to 7 weeks gestation 30 showed failure rates between 15 and 23 in 1,000. Over half of these procedures were manual vacuum aspirations, with around 40% suction curettage.18
Contraceptive prevalence is the percentage of women who are currently using, or whose sexual partner is currently using, at least one method of contraception, regardless of the method used. It is usually reported for married or unmarried girls aged 21 to 25 years.19
In India each year an estimated 453 women die due to maternal causes for every 100,000 live births (UNFPA 1997). This statistic masks the vast variation among states. While national and state estimates are imprecise, they are able to represent certain trends. Orissa and Madhya Pradesh had approximately 738 and 711 maternal deaths per 100,000 births in 1992. Among the large states, Kerala has a singularly low ratio of 87 maternal deaths reported per 100,000 births. On an average, roughly fifteen percent of maternal deaths in India are thought to result from unsafe abortion (Chakra and Nona 1994).20
Only 54 women (32.1%) presented within 72 hours after intercourse. This is due to lack of awareness. All women coming up to 10 days after coitus were provided with Yuppie method. There were 42 adolescent girls, 28 unmarried women and 98 married women in this study. The large majority of the 54 women who presented within 72 hours were adolecent girls or unmarried women. The time of intercourse in relation to menstrual cycle was analyzed. It was found that 58.3% of these women had coitus in the ‘unsafe.21
The study was conducted sexually active age by 21 to 25 years 77% of females and 86% of males have been sexually active. The average time between the initiation of sexual activity and the pursuit of medical advice about contraception, however, is one year. Even then, many unmarried girls are use contraception only inconsistently or not at all.22
In five states of Haryana, Orissa, Rajasthan, Tamil Nadu and Uttar Pradesh in 1983-84. According to ICMR findings, for the five states combined, 19 per 1000 pregnancies were terminated. Six per thousand were terminated legally, and 13 per 1000 pregnancies were terminated illegally. Applying these proportions to 1990 national abortion data implies that the approximately 600,000 legal abortions reported in 1990 indicate that in total 1.3 million illegal abortions were performed nationwide (Indian Council of Medical Research 1988; World Bank 1996). The ICMR national abortion estimate is substantially lower than Chakra and Nona’s widely cited pregnancy are recommended to undertake further abortion procedure when either medical or surgical abortion has failed. 23
Abortions were performed nationwide (Indian Council of Medical Research 1988; World Bank 1996). The ICMR national abortion estimate is substantially lower than Chakra and Nona’s widely cited various drugs have been used for medical termination of pregnancy. The most commonly used prostaglandins are gemeprost given vaginally and misoprostol, either oral or vaginal. It has a strong uterotonic effect and is used to the pregnancy terminations illegally in some parts of the world (Blanchard 1999, Costa 1998). The reported complete abortion rate for misoprostol alone varies between 61% for single and 93% for repeat doses (Bungalow 1996, Carbon ell 1997). Gemeprost used alone was less effective to induce complete Abortion than in combination with mifepristone (Norman 1992). (Birdman 1985).(WHO 1997).24
(Indian Council of Medical Research 1988; World Bank 1996). The ICMR national abortion estimate is substantially lower than Chakra and Nona’s widely cited Various drugs have been used for first trimester abortion is illegally in some parts of the world (Blanchard 1999, Costa 1998). The reported complete abortion rate for misoprostol alone varies between 61% for single and 93% for repeat doses (Bungalow 1996, Carbon ell 1997.25
In the Seventh Five-Year Plan (1985-1990) the Government of India stated the intention to equip all primary health centres with staff and supplies to conduct abortion services.. Around one-quarter of primary health centres in Uttar Pradesh and Maharashtra provide abortion services. One-third and almost two-thirds provide these services in Gujarat and Tamil Nadu, respectively. Among community health centres only 59 percent in Uttar Pradesh and 78 percent in Gujarat provide abortion services. Eighty-nine percent of community health centres provide MTP in Maharashtra. In Tamil Nadu, 95 percent of community health centres and sub-district hospitals provide MTP service. (Khan et al. 1999).26
Unmarried girls out of 83 undergoing75 (90%) undergoing included in abortion More than 50% of unmarried girls had a friend or fiancée as their sex partner. Incest was responsible for pregnancy in 16% cases. 11% teenage girls were undergoing abortion for second or third time. 42% sought abortion in the second trimester of pregnancy.56% of the abortions were carried out at unapproved centers by unqualified personnel. Confidentiality and procedure's cost factor were given more importance than safety consideration by 89% of the abortion seekers. Contraceptive awareness was low, awareness regarding AIDS (though low at 47%), was higher than that for STDs in general (31%). Despite the awareness of use of condom as a contraceptive method, only 21% girls persuaded their partners regarding its uses.27
Studies show that unmarried adolescents and women undergoing sex selective abortion are the groups most likely to attempt second trimester abortion (Gantry et al. 2000; Rae and Rae 1990, Aras et al. 1987). Adolescents are particularly prone to abortion related morbidity and mortality. In 1995 almost 50 percent of deaths among women age 21 to 25 were abortion related. This implies that around twenty percent of abortion-related deaths occur among adolescents (Government of India and as found in Mathew 1998)28
In the current situation medical termination are not adequately decentralized and regularity reform will have to take place before centralization of legal services will be in a meaningful way. At present time with the entire focus of unmarried girls health, investigation from her own experiences and discussion with experts, she felt that educating the unmarried girls are very important on medical termination of pregnancy as well as selected contraceptive oral pills and so, she selected self instructional module for educating the unmarried girls to increase their knowledge on medical termination of pregnancy by selected contraceptive oral pills.
6.2 REVIEW OF LITERATURE
Review of literature is a key step in research process. it makes to the new knowledge insight and general scholarship of the researcher. It is an extensive, exclusive and systematic examination of publication relevant to the research project.
The literature review related to the present study is organized and presented under the following heading.
Studies related to importance of medical termination of pregnancy and selected contraceptive method
The study was conducted to assess the knowledge on the current status and risk factors of abortion of women at reproductive age in rural area of Xian district. Interview was conducted. there were 5844 pregnant women under study with a total number of 9638 pregnancies including 1153 abortion .among the pregnant women in rural area, the abortion rate was 13.6% .the risk of having abortion would increase among women who were age .> or 25 years and those with more than 3 pregnancies. The study concluded that in order to reduce the incidence of abortion. 29
The purposive study was conducted, to assess the knowledge and practice of women in Chatrakodihalli and Beglihoshalli villages of Kolar.The study were selected simple random technique for 150 married women. Reliability of the tool was tested and validity was ensured in consultation with the guides and experts in the fields of medicine and nursing. With regard to knowledge assessment, the mean percentage of the women was 42.59% Area wise mean percentage was 49.92% in the areas of general information regarding abortion, 28.33% on complications of abortion and 45.37% in the area of prevention and after care of abortion. However most of the women had inadequate knowledge. Practice assessment was done on those women who had experienced abortion. Out of 150 women, only 10 of them had abortion and the mean percentage of practice scores were 45.83% indicating that the women had good abortion practices.30
A study was conducted on awareness and practice family planning methods in women attending gynecology OPD at Nepal, A cross-sectional descriptive study of awareness and practice of family planning methods among 200 women of reproductive age most of the respondents 93.0% were aware of at least one of oral contraceptive methods out of ten methods, but only 65.0%had ever used it and contraceptive prevalence rate was 33.5%which was slightly higher than the national data as 28.5% knowledge about emergency contraceptives was quite low 12.o%as it was newly introduced in the country. The study concluded that the use of communication media suitable for the audience and adequate message is important in conducting effective family planning activities .31
A study was conducted on knowledge of oral contraception among women coming induce abortion, government medical college and hospital ,Chandigarh ,Indian a survey was conducted over a period of 6 months with the help of redesigned questionnaire, in 100 consecutive women attending our voluntary abortion medical termination of pregnancy clinic for an induce abortion .The result shows only 27% of women were using regular contraception .only the women out of 100 was aware of oral contraceptive oral pills. The study conclusion that oral pills is widely published and used as a back up to prevent unwanted pregnancies.32
A community based study was determinants of contraceptive use among ever unmarried women in rural Mangalore, Karnataka. A cross sectional study was conducted. The total sample sizes of 160 by the formula for infinite population 4pq/d 2.Assumed a 10 percent non response rate. The result of the study was 55.8% prevalence of contraceptive use. Unmarried women used ORAL PILLS 8.3% . The study concluded that shows higher literacy among unmarried women and economic independence has played an important role in promoting contraceptive use.33