Public sector serving poor women for comprehensive abortion care: IDF study

New Delhi: Maternal mortality, which primarily impacts developing countries, reflects the health divide between rich and poor. Reducing maternal deaths requires strengthening maternal health services, including comprehensive abortion care (CAC), by ensuring the presence of qualified staff and increasing the use of public sector facilities by women. The State of Madhya Pradesh is one among six states with significantly higher Maternal Mortality Ratio (MMR) than the national average (221 compared to 167 deaths per 100,000 live births). Madhya Pradesh is one of India’s largest states with a population of 73.34 Million people and about three-fourths of them living in rural areas.

In 2006, the state government of Madhya Pradesh with technical support from Ipas Development Foundation (IDF) began a concerted effort to ensure access to CAC services at all levels of public health facilities, including primary, secondary and tertiary level facilities. Key IDF interventions include working closely with the State Government to train doctors, orient nursing staff, liaison with state and district officials for facilitating the availability of essential equipment and drugs, as well as establishing site signage (poster or wall sign) on the availability of CAC services. The primary goal of this ongoing intervention is to ensure access to free of cost, safe and early CAC services for women, especially poor women.

An in-depth study undertaken by IDF recently published in The BMC Health Services Research (BioMed Central) journal explored the socio-economic profile of women accessing CAC services at different levels of public health facilities in rural and urban Madhya Pradesh. This study specifically examines 1) if public sector facilities are offering CAC services to women, 2) socio- economic profile of women varied by type of public sector facilities, and 3) if women incurred any out-of-pocket cost (indirect) to access services in terms of transportation, food, clinical examination, and medicines.

A total of 1036 women presenting to 19 randomly selected facilities for induced abortion and post-abortion care, provided informed consent, were interviewed between May and December 2014. Seventy-two percent (n = 742) of respondents were interviewed at selected primary level health facilities (primary and community health centers) and 28% were interviewed at secondary level hospitals (including sub-district and district hospitals).

This is one of the first studies in India that examines the profile of women seeking safe abortion services at public sector facilities and evaluates this access in the context of socio-economic status. Dr Sushanta Banerjee, Senior Director, Research and Evaluation, IDF explains, “Results highlight that overall 57% of women who received CAC services at public health facilities were poor, followed by 21% moderate and 22% rich. More poor women sought care at primary level facilities (58%) than secondary level facilities and among women presenting for post-abortion complications (67%) than induced abortion”. For the purpose of the study, a composite index was constructed based on the ownership of household assets and durables and finally, the index score was stratified into three categories including poor, middle, and rich households.

“It is very encouraging to note the findings of the study suggest that poor women are predominantly visiting public health facilities for availing CAC services,” said Dr Archana Mishra, Deputy Director, Maternal Health Services, Government of Madhya Pradesh. This study also reaffirms efforts taken by the Government of Madhya Pradesh for extending health services to the poorest women.

It was also encouraging to note that services were offered at these public facilities free of cost. Women, however, did report out of pocket expenses towards travel to facilities and medicines. Women who sought services at PHCs had to travel an average of 13 kms and 26 kms for secondary level facilities. Distance has a time and cost implication on women and their families and may be a deterrent in availing facilities from a trained provider despite being free of cost.

Although this study was conducted in Madhya Pradesh, the findings have a national implication on the role of the public health system serving poor women. Mr Vinoj Manning, Executive Director, IDF said that, “the study reaffirms the importance of our work in the country on strengthening access to CAC services in the public sector as it is the only way to ensure access to safe abortion services for poor women. It also underlines the need for increasing access to CAC services across the country”.