Reproductive Health M0968-8080/09PII: S0968-8www.rhm-elsevier.com
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ctive Health Matters.ts reserved.atters 2009;17(33):70–79
$ – see front matter080 (09 ) 33439-4 www.rhmjournal.org.uk
Support for provision of early medical abortion bymid-level providers in Bihar and Jharkhand, India
Lisa Patel,a Trude A Bennett,b Carolyn Tucker Halpern,bHeidi Bart Johnston,c Chirayath M Suchindrand
a PhD graduate, Department of Maternal and Child Health, University of North Carolina, Gillings School ofGlobal Public Health (UNC Gillings School), Chapel Hill NC, USA. E-mail: [email protected]
b Associate Professor, Department of Maternal and Child Health, UNC Gillings School, Chapel Hill NC, USAc Social Scientist, ICDDR,B, Dhaka, Bangladesh, and Adjunct Assistant Professor, Department of Maternal andChild Health, UNC Gillings School, Chapel Hill NC, USA
d Professor, Department of Biostatistics, UNC Gillings School, Chapel Hill NC, USA
Keywords: medical abortion, task shifting, mid-level providers, training of service providers, India
THE 1971 Medical Termination of PregnancyAct greatly liberalized the social and medi-cal conditions in which women in India
may access safe abortion services. However,access remains difficult due to factors such asthe limited availability of trained providers,especially in rural areas, where three-quartersof the population live. Rural areas are servedlargely by untrained or inadequately trainedproviders. Even where licensed facilities exist,they may not provide abortions because of lackof equipment and supplies or a lack of trained
providers.1–8 Current abortion policy in Indiaexcludes non-physicians from being trained asabortion providers. Only registered physiciansmeeting specific training and experience require-ments at hospitals or clinics approved by thegovernment may legally provide abortion ser-vices.9 Annually, an estimated 450 maternaldeaths occur per 100,000 live births in India.10Unsafe abortion is a significant cause of thesedeaths, accounting for an estimated 9–20% ofthe total.1,11–14 To help solve the problem ofunsafe abortion, the World Health Organization
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recommends increasing the numbers of properlytrained and adequately equipped personnel,using proven abortion methods and providingabortion services at the lowest appropriate levelof the health care system.15 Interest in involvingmid-level health care providers in a variety ofmedical roles, including in abortion provision,has been increasing worldwide.16 Mid-level pro-viders include a wide range of non-physicians(physician assistants, nurses, midwives andothers) who differ in training and responsi-bilities from country to country but carry outclinical procedures, including those related toreproductive health.15 In most regions of theworld, mid-level providers outnumber physi-cians; they often work in closer proximity towhere women live and can often offer moreaffordable services.15–18Medical abortion using mifepristone and miso-
prostol is safe and effective11,19–22 and wasapproved by the Drug Controller of India in 2002up to 49 days of pregnancy.23 In a country likeIndia, where abortion-related morbidity andmortality are high and the health infrastructurecan limit access to safe aspiration abortions,medical abortion could greatly improve safetyand access by increasing the number, cadre andgeographic distribution of health care providerswho can be trained.24,25 Medical abortion doesnot require extensive infrastructure. In additionto mid-level provider interest and the necessarypolicy changes, an enabling environment, includ-ing the support of physicians, is critical.Many mid-level providers already do abortions
in response to community demand.26–28 How-ever, little evidence exists on their interest inbeing trained to offer medical abortion servicesor on the views of physicians about their doingso.23,29–32 A study in Bihar and Jharkhand in2004, conducted around the same time as datafor the current study were collected, and a 2003survey of members of the Federation of Obstetricand Gynaecological Societies of India both foundthat the majority of obstetrician-gynaecologistsknew about mifepristone-misoprostol and reportedproviding abortions using one or both drugs.23,33Few general physicians or other types of healthcare providers in Bihar and Jharkhand havereported providing mifepristone-misoprostol.33,34A 2005 qualitative study from south India foundthat 12 of 37 private sector physicians who partic-ipated in the study and who provided abortions
were providing medical abortion services; villagehealth nurses interviewed said they had no know-ledge of medical abortion.32Bihar in India was divided into two states,
Bihar and Jharkhand, in 2000. Nearly 85% ofthe population in Bihar and 75% in Jharkhandlive in rural areas.35,36 Both states have rela-tively poor socio-economic and health indicatorscompared to other states in India, including highrates of poverty, illiteracy and infant and childmortality.35–37 They also have relatively hightotal fertility rates, high unmet need for familyplanning and low numbers of deliveries in med-ical facilities.35,36 Furthermore, both states havehigh estimated rates of abortion, but limitedapproved facilities offering abortion services.1,33This study aimed to assess the environment
for mid-level providers to participate in early med-ical abortion provision in Bihar and Jharkhand,including factors associated with mid-level pro-vider interest in training for earlymedical abortion,the attitudes of obstetrician-gynaecologists andgeneral physicians towards them doing so andthe factors that influenced their attitudes.
MethodologyThe data come from a larger project which soughtto assess the effectiveness and cost-effectivenessof clinic-franchising programmes in improvingthe delivery of family planning services and useof contraception in Bihar and Jharkhand.38 Theproject applied a multi-stage cluster sampledesign to the entire area making up the currenttwo states (except for some districts that wereunsafe for fieldwork) to obtain samples of gov-ernmental, non-governmental (NGO) and privatehealth facilities providing family planning ser-vices and their clinical staff.38,39 Large hospitalswith more than 50 beds were excluded.38 Thesurveys of health facilities and their staffwere piloted and carried out between May andAugust 2004.Health facility heads were approached by a
pair of male and female field interviewers forconsent. All staff in the facilities were enumer-ated; all those who were authorized to providefamily planning services and who consented toparticipate were interviewed. The achieved sampleincluded 1,346 health facilities and 2,039 staffproviding family planning. The response rate forproviders was 84%. Heads of health facilities were
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interviewed about the types of reproductivehealth services offered and the number, typeand service capacity of their staff. The staffquestionnaire covered socio-demographic char-acteristics, services offered by the provider,training experience and referral behaviour. Aseparate medical abortion module was deve-loped and added to the health facility staff ques-tionnaire for this study.To assess the mid-level providers' interest in
attending mifepristone-misoprostol training forearly abortion, we asked them: “If a seminar ortraining on mifepristone and misoprostol forearly abortion were offered in the future, wouldyou be interested in attending? (yes/no)”. Toassess the obstetrician-gynaecologists' and gen-eral physicians' attitudes towards non-physiciansbeing trained for this, we asked them: “Shouldhealth care providers other than physicians beeligible to be trained and to provide early medicalabortion? (yes/no)”.Family planning provider explanatory vari-
ables included: attitude towards abortion, currentabortion provision or help with abortion provi-sion using mifepristone-misoprostol, currentabortion provision using any pharmacologicaldrugs and sex of provider. Health facility explan-atory variables were: type of health facility wherethe provider worked, obstetrician-gynaecologistsand general physicians on staff at the healthfacility, and mid-level providers on staff at thehealth facility. Not all explanatory variables wereincluded in every analysis.Attitude towards abortion was measured by
asking: “Under which of the following (ten) con-ditions or situations do you personally believe awoman should be able to have an induced abor-tion?” Seven “yes” answers (the modal score)were labelled as a “permissive” attitude, fewerthan seven as “less permissive” and more thanseven as “more permissive”. All family planningstaff were asked whether they provided or helpedto provide any kind of abortion services, and ifyes, which ones (manual or electric vacuumaspiration, D&C and medical abortion usingmifepristone-misoprostol). The measure, currentabortion provision or help with abortion provi-sion using mifepristone-misoprostol (yes/no)was created from this question. All providerswere also asked: “Do you currently use any phar-macological drugs in your practice to induceabortions?”. This question was used to create
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the two-category measure, current abortion pro-vision using any pharmacological drugs (yes/no). Sex of provider (male/female) was notedby the interviewers.The type of health facility where the provider
worked was categorized as a government, pri-vate facility, or other facility (franchised NGOfacilities, NGO facilities and private unqualifiedhealth clinics). All heads of health facilities wereasked what type of and how many cliniciansprovided family planning services at their facil-ity. The measures obstetrician-gynaecologistsand general physicians on staff (yes/no) andmid-level providers on staff (yes/no) were cre-ated from responses to this question.Data were analyzed using Stata 9.2; all anal-
yses were weighted and adjusted to accountfor the clustered sampling design. Three sub-populations were created for analysis: mid-levelproviders (unweighted n=263), obstetrician-gynaecologists (unweighted n=54) and generalphysicians (unweighted n=88). Mid-level pro-viders in this study included auxiliary nurse mid-wives (ANMs), lady health visitors (LHVs), malehealth workers (MHWs), nurses and paramedics.In India, ANMs, LHVs, and MHWs work at gov-ernment facilities only, have completed at mini-mum 10 years of schooling plus a diploma courseand are responsible for providing family plan-ning and preventive services, referrals, keepingrecords and treating minor ailments. Nurses andparamedics work at a variety of health facilities,usually have a college degree and assist physi-cians in taking care of patients and carrying outtasks such as administering medication, chang-ing dressings and preparing patients for surgery.In this study, obstetrician-gynaecologists includedphysicians who reported that they had an MD/MS/DNB in Obstetrics and Gynaecology or a Post-graduate Diploma in Obstetrics and Gynaecology.General physicians were doctors who stated theyhad an MBBS degree.Bivariate analyses using logistic regression
examined associations between mid-level pro-viders' interest in attending training for earlymedical abortion and selected provider and healthfacility variables. Multivariate logistic regressionwas used to assess the association between mid-level providers' interest in attending medicalabortion training and the variables sex of pro-vider, attitude towards abortion, current abortionprovision using any pharmacological drugs, type
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of health facility where they worked, and whetherthere were obstetrician-gynaecologists and/orgeneral physicians on staff at their health facility.The model controlled for mid-level provider age(years), education (primary/secondary/completedsecondary or more), and health facility location(urban/rural).Bivariate analyses examined associations
between selected provider and health facilityvariables and physicians' attitudes towards non-physicians being trained to provide early med-ical abortions. Two separate logistic regressionmodels, one for obstetrician-gynaecologists andone for general physicians, estimated the rela-tionship between attitude towards non-physiciantraining and the variables: attitude towards abor-tion, current abortion provision or help with abor-tion provision using mifepristone-misoprostol,mid-level providers on staff at the health facility,and type of health facility where the providerworked. Both models controlled for provider sex(male/female), age (years) and health facility loca-tion (urban/rural).
FindingsCharacteristics of providersThe majority of family planning providers inBihar and Jharkhand held “permissive” or “morepermissive” attitudes towards abortion. Overall,15% of mid-level providers, 45% of obstetrician-gynaecologists and 16% of general physicianshad a “more permissive” attitude (Table 1). Themajority in each group reported providing or help-ing to provide abortion services: 55% of mid-levelproviders, 73% of obstetrician-gynaecologistsand 92% of general physicians. Twelve per centof mid-level providers reported providing anypharmacological drugs for abortions. Forty-eightper cent of all obstetrician-gynaecologists offeredpharmacological drugs for abortion and 31%reported using mifepristone-misoprostol. Thirtyper cent of general physicians reported providingany pharmacological drugs, with 17% reportingproviding mifepristone-misoprostol.Most mid-level providers were based at gov-
ernment health facilities, whereas the majorityof obstetrician-gynaecologists and generalphysicians worked at non-public facilities. Mostmid-level providers and general physiciansworked at rural health facilities, whereas the
majority of obstetrician-gynaecologists prac-tised in urban areas.
Mid-level provider interest in early medicalabortion trainingOverall, 74% of mid-level providers showed inter-est in training for early medical abortion (Table 2).A significantly higher proportion of men (94%)compared to women (70%) expressed interest.
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Ninety per cent of mid-level providers who hadprovided pharmacological drugs for abortionshowed interest in attending training. Almost halfof those working in private health facilities andover three-quarters in government facilities wereinterested. Bivariate analysis showed that interestwas not associated with attitude towards abor-tion, current abortion provision using any phar-macological drugs, type of health facility wherethe provider worked, or presence of obstetrician-gynaecologists or general physicians at thehealth facility. Mid-level provider sex was theonly variable that was statistically significantlyassociated at the bivariate level with interest intraining for early medical abortion provision.In the multivariate logistic regression model,
sex of provider, attitude towards abortion, cur-rent abortion provision using any pharmacolog-ical drugs, and type of health facility where theprovider worked were associated with mid-level
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provider interest in attending early medicalabortion training (controlling for provider age,education and health facility location). Malemid-level providers were much more likely tobe interested than females (OR 5.79, p<.05).Mid-level providers reporting more permissiveabortion attitudes were significantly more likelyto be interested in training than those with lesspermissive attitudes (OR 5.06, p<.05). Currentproviders of abortion using any pharmacologi-cal drugs were also more likely to be interestedcompared to those not providing such drugs (OR4.50, p<.05). Furthermore, those working at pri-vate health facilities were much less likely to beinterested than those at government facilities(OR .05, p<.05).
Attitudes of obstetrician-gynaecologistsOverall, 34% of obstetrician-gynaecologistswere supportive of non-physicians' participation
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in early medical abortion provision (Table 3).However, bivariate analysis showed that 95%of those with more permissive attitudes toabortion were not supportive, and only 11% ofthose working with mid-level providers weresupportive. In contrast, 82% of obstetrician-gynaecologists who did not work with mid-levelproviders were supportive of non-physiciansreceiving training.
In multivariate analysis, obstetrician-gynae-cologists with more permissive abortion atti-tudes (OR 0.01, p<.05) and those who providedabortions using mifepristone-misoprostol (OR0.03, p<.05) at the time of the survey were sub-stantially less likely to be supportive of non-physician provision of early medical abortion(after controlling for provider sex, age and healthfacility location).
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Attitudes of general physiciansFifty-eight per cent of general physicians sup-ported non-physicians being trained in earlymedical abortion provision (Table 3). Bivariateanalyses found significant differences in extentof support depending on the type of health facil-ity where they worked. A slightly lower percent-age of general physicians working at privatefacilities were supportive compared to those ingovernment facilities.Multivariate analyses (after controlling for pro-
vider sex, age and health facility location) foundthat general physicians working for private (OR0.02, p<.01) or other types of health facilities(OR 0.04, p<.05) were substantially less likelyto support non-physician training compared tothose at government facilities.
DiscussionThis study shows that the majority of mid-levelproviders interviewed in Bihar and Jharkhandwere interested in being trained to provide earlymedical abortion in 2004. Since then, medicalabortion drugs have become more commonlyavailable throughout India, and it is highly likelythat interest in providing them has also risenamong providers.The fact that male mid-level providers were
more likely to be interested in pursuing earlymedical abortion training compared to theirfemale counterparts was counter to expectations.No published studies to our knowledge haveexplored this difference. However, in this regionmen are traditionally the main income generatorsand perhaps they were quicker to perceive thepotential to increase their income by learningnew skills. How women needing an abortionwould feel about male providers of medical abor-tion is not known. Women in India have reportednot seeking out health care if a female provideris not available, due to fear and embarrass-ment of being examined by a male health careprovider.40–42 However, receiving medical abor-tion drugs from a man may not concern womenas much, as it is a non-invasive process.Our findings as regards permissive attitudes
towards abortion and interest in training wereconsistent with findings from research in theUnited States among nurse practitioners, physi-cian assistants and certified nurse-midwives,whose favourable attitudes towards abortion were
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associated with their desiring medical abortiontraining.31 Not only do a high number of mid-level providers in Bihar and Jharkhand want toparticipate in early medical abortion training,but those already providing medical abortionwere more likely to want to obtain the properskills to do so.Mid-level providers working at private, for-
profit facilities were less likely to be interestedin training compared to those working at gov-ernment facilities. This may be because thoseat private, for-profit facilities were likely to haveclearly delineated roles and responsibilities withfewer opportunities for advancement. We hadexpected that providers working at facilities withno physicians on staff might be more likely towant training, in order to satisfy the needs ofabortion seekers in their communities. This didnot prove to be the case, however.Overall, physicians in Bihar and Jharkhand
were fairly supportive of non-physicians beingtrained to provide early medical abortion ser-vices. These results come from small samples;hence, the standard errors are large and confi-dence intervals wide. Nevertheless, our findingsunderscore important differences betweenobstetrician-gynaecologists and general physi-cians in this region. General physicians weremuch more supportive of non-physician trainingfor early medical abortion than obstetrician-gynaecologists. A higher percentage of generalphysicians also reported providing or help-ing to provide abortion services compared toobstetrician-gynaecologists, which was unex-pected. These differences may be related to the factthat the majority of obstetrician-gynaecologistspractised in urban areas and general physicianslargely worked for rural facilities. The majorityof the population in Bihar and Jharkhand is ruralwhere there are few obstetrician-gynaecologistsand a high demand for abortion services. In thesecircumstances, general physicians may be morelikely to see the consequences of lack of accessto safe abortion services.On the other hand, obstetrician-gynaecologists
who were providing medical abortion may havehad concerns about the capabilities of lesstrained clinicians to prescribe medication andmanage patients appropriately. Alternatively,their lack of support may have been due tosimple income-related reasons. The more pro-viders there are, the more competition there is
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and potentially the less income. Obstetrician-gynaecologists may also feel territorial, as abor-tion is a service they have traditionally provided.The fact that the general physicians working inprivate health facilities were less likely to be sup-portive of non-physician provision of medicalabortion than those in government facilitiesmay be based on similar economic reasons.This study has three important limitations. First,
clinics with more than 50 beds were excluded inthe sampling design, so the findings may not begeneralizable to all health care providers andfacilities in the two states. Secondly, we werenot able to conduct in-depth interviews withrespondents to learn the reasons for their views.This limited our interpretation of the findings,though some explanations are supported byother research. A final limitation is the cross-sectional nature of this study. Cross-sectionalstudies can investigate associations between var-ious factors and outcomes of interest. However,because they are carried out at one point in timeand can give no indication of the sequence ofevents, it is impossible to infer causality.
ConclusionThis study has identified an enabling environ-ment for expanding authorization and trainingfor mid-level providers to offer early medicalabortion. A majority of mid-level providers sur-veyed expressed an interest in receiving trainingto provide medical abortion services. Additionally,
physicians, particularly those in the public sector,supported such training. Policymakers and otherstakeholders should take advantage of this sup-portive environment by increasing the pool ofcadres who can legally provide safe abortionservices. This is particularly relevant for Biharand Jharkhand, as the majority of the pop-ulation in both states are based in rural areas,where non-physician providers are the front-linehealth workers.While the majority of general physicians
surveyed were supportive of mid-level provid-ers offering medical abortion, the majority ofobstetrician-gynaecologists were not. Thosewho support this form of task shifting shouldseek to work with physicians who have reserva-tions about it. Over time, and with experience ofmid-level providers' skills and capabilities, thesereservations may be reduced, as has occurred inthe United States in the past two decades.43 Asregards the substantial minority of obstetrician-gynaecologists and general physicians who haveless permissive attitudes toward abortion, valuesclarification activities may be helpful, and expo-sure to the public health justification for reducingmaternal mortality from unsafe abortion. Possi-bly the best strategy for achieving safe abortionis to permit trained mid-level providers to offerabortion services, especially in rural communities.This study suggests that the majority of providersin Bihar and Jharkhand support this idea andwould avail themselves of training and servicedelivery opportunities if they were offered.
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RésuméL'avortement médicamenteux peunombre, le type et la distributiondes prestataires de services d'avortemen Inde. Cette étude porte sur unprestataires de planification familiamoyens, 54 gynécologues-obs88 médecins généralistes) interroenquête de 2004 sur les établissemet leur personnel au Bihar et JhaElle a répertorié les facteurs al'intérêt des cadres moyens pour uà l'avortement médicamenteua examiné si les gynécologues-et les médecins généralistes soformation de non-médecins àet quels facteurs influençaient leLes conclusions montrent des nd'intérêt de la part des cadres msoutien raisonnable des médecinsun homme, d'avoir une attitude pà l'égard de l'avortement et deavortements pharmaceutiques éun plus grand intérêt des cadresla formation. Les cadres moyendes établissements privés avaieprobabilités d'être intéressés. Unepermissive à l'égard de l'avortemend'avortements avec la mifépmisoprostol était inversement assocque les gynécologues-obstétriciensla pratique d'avortements médicades non-médecins. Les médecinbasés dans des établissements priétaient moins favorables que ceupublics. Les conclusions de l'étudque les décideurs doivent élargirprestataires qui peuvent légalem
gynaecological morbidity inSouth India: Causes andremedies in a cultural context.Journal of Family Welfare 2000;46(1):31–38.
42. Helen BJ, Prasad S, Abraham K,et al. Reproductive TractInfections Among YoungMarried Women in Tamil Nadu,
t accroître legéographiqueent médicalisééchantillon dele (263 cadrestétriciens etgés pour uneents de santérkhand, Inde.ssociés avecne formationx précoce etobstétriciensutenaient laces servicesurs attitudes.iveaux élevésoyens et un
. Le fait d'êtrelus permissivepratiquer destait associé àmoyens pours basés dansnt moins deattitude plust et la pratiqueristone et leiée au soutienapportaient àmenteux pars généralistesvés ou autresx des centrese confirmentle groupe deent pratiquer
ResumenLos servicios de aa aumentar elgeográfica de prseguro en la Indimuestra de prov(263 de nivel in88 médicos geneen 2004 con psalud en Biharidentificaron losde los profesiorecibir capacitacde aborto conexaminó si losgenerales apoyano médico en estque influyeron edemuestran altolos prestadores dapoyo de los mnivel intermediomás permisivaservicios de abortmayor interés ende nivel intermetendían a mostrmás permisivasabortos con mifasociadas invegineco-obstetramedicamentos pogenerales en estamenos apoyo qupúblicos. Estosformuladores dede prestadores dlegal en la India
India. International FamilyPlanning Perspectives 2005;31(2):73–82.
43. Berer M. Provision of abortionby mid-level providers:international policy, practiceand perspectives. Bulletin ofWorld Health Organization2009;87(1):58–63.
borto con medicamentos tiendennúmero, tipo y distribuciónestadores de servicios de abortoa. Este estudio informa sobre unaeedores de planificación familiartermedio, 54 gineco-obstetras yrales), de una encuesta realizadaersonal y establecimientos dey Jharkhand, en la India. Sefactores asociados con el interésnales de nivel intermedio enión en la prestación de serviciosmedicamentos temprano, y segineco-obstetras y médicos
ban la capacitación del personalos servicios, así como los factoresn sus actitudes. Los resultadoss niveles de interés por parte dee nivel intermedio y considerableédicos. Entre los prestadores de, ser hombre, tener una actitudhacia el aborto y proporcionaro con fármacos, se asociaron conla capacitación. Los prestadoresdio en establecimientos privadosar menos interés. Las actitudeshacia el aborto y la práctica deepristona-misoprostol estabanrsamente con el apoyo de loss a la práctica de abortos conr personal nomédico. Losmédicosblecimientos privados brindarone aquéllos en establecimientosresultados confirman que lospolíticas deben ampliar el grupoe servicios de aborto seguro y.
