The mean age of the married females who participated in the FGDs were 30.9yrs (SD-11.9, n = 26), mean age for married males was 51.2 yrs (SD- 16.4, n = 7), and for ASHA was 38.4yrs (SD-10.9, n = 6). Three themes were identified based on the data generated through FGDs and IDIs: beliefs surrounding induced abortions, reasons and practices for induced abortion, and facilitators and barriers for safe abortions.
Belief surrounding induced abortions
Most of the respondents from the community considered a pregnancy to be a blessing from God, and hence regarded abortion as a sin. However, an abortion done after detection of a congenital anomaly in the baby was not considered as a sin. They attributed the act of abortion of a healthy baby as a violation of the right to live for the fetus. A 37-year-old man said, “Woh bhagwan ki ichha hai, aur hum bhagwan ke khilaf thodi ja sakte hai, jeev ko paida karna hai palne ki jimedari bhi usspe hai na, jeev ki koi galti thodi hai jo usse mar rahe” (It is God’s decision to make a life, how can we go against God? If you conceive a life, then it is your responsibility to raise it. It is not the fault of the baby that you made it.), while a 28-year-old married female said, “Baccha girana atyachaar hai, sarasar galat hai.” (Abortion is a violation of the right to live). A 27-year-old married female said, “Bacche mai koi dikkat hai, toh galat nahi hai” (If there is an anomaly in the fetus then aborting it is not wrong).
The village community leader and elderly males of the community believed that an unmarried female conceiving a pregnancy was a ‘big sin’, and an abortion post conception an even bigger sin. The sarpanch (village council leader) said, “Shadi se pehle bachha karna paap hai aur bachha girana aur bada paap hai” (Getting pregnant before marriage is a sin and aborting such a baby is an even bigger sin).
The healthcare providers and healthcare-associated government officials in the community unanimously held the belief that abortion in itself is a normal procedure, but when done after illegal sex determination is an issue. “As such, sex determination is not a bad thing, it is a good thing provided you are concerned what needs to be done for the baby, pertaining to our patriarchal society sex determination should not be done, as it affects the mental and physical health of the patient and sometimes may lead to septic abortions", said a gynecologist working in a sub district hospital.
Reasons for induced abortion
The primary reasons to plan an induced abortion in the community was attributed to preference to have a male child, higher number of children in the family, congenital deformities in the fetus, contraceptive failure and low socioeconomic status of the family. A 30-year-old married female said, “Zyada bacche ho jaate toh safaai karani padhti hai” (if the number of children is more, then abortion is required). A 28-year-old female said, “Bacchen mei dikkat ho toh janam deke kuch hona toh nahi hai, bas dukh aur badhega” (giving birth to a child with a congenital anomaly will only perpetuate the misery). The gynecologist said, “Families completed with 2–3 living children and having issues with current contraception do opt for abortion”. Attributing their lower socioeconomic status, a 31-year-old married female said, “Itni mehngai hai, inki padhai likhai kaun karwayega”(it is difficult to provide good education to more kids in these expensive times), while a 30-year-old male in the community said, “Itne jyada bacho mai to palan poshan ki dikkat aati hai, jitne jyada bache maa bhi utni kamjor aur bache bhi” (It is difficult to raise multiple children with provision of adequate nutrition to each; more the number of children weaker are the mother and the children).
Males in the society were particularly found to prefer a male child as that child was considered the heir to the family. They considered a girl child a burden who would get married into a different family and they would have to pay a huge dowry for her. A 45 year old male said, “ladki paraya dhan hai, apne pass kuch rahta nhi, ladka hua to apne pass rahta hai” (girl has to go to her husband's home after marriage, boy only will stay with us ), while the sarpanch said, “Gaon mei abhi bhi vansh chalane ki reeti chali aa rahi hai, ladka chahte hai.., dahej hi kha raha hai ladkiyon ko” (People in villages here still believe in the concept of lineage and that only boys can take it forward, dowry is a major problem which is forcing people to avoid accepting a girl child). Compared to the males, most of the female in the community strongly believed that a girl child was a manifestation of the Goddess of Wealth and preferred to have at least one girl child in their family. A 25 year old ASHA said, “Ghar mein ladki toh lakshmi ke saman hoti hai” (girl child in a house is equivalent to goddess Lakshmi).
Community Practices for induced abortion
Methods to get an elective abortion used in the community included methods of modern medicine like tablets and surgical procedures like dilation and curettage. In the community we also found few traditional methods to be also prevalent like eating turmeric, carrot seed, almonds, carom seeds, fennel seeds. An ASHA worker said, “woh toh garam cheezein jaise haldi aur garam doodh, badaam, ajwain, saunf khaate hain bacha giraane ke liye” (Foods with ‘warm’ intrinsic property are used for abortion in the village).
The decision to get an abortion at times solely lies with the husband and/or the mother-in-law. A 29-year-old married female said, “Aurat nahi chahti ladki girana, gharwale aur saas chahte hai'' (Pregnant women don’t opt for female foeticide, it’s decided by mother-in-law and other family members.), this was also confirmed by a private pharmacist said, “Pati aur saas ka decision hota hai” (husband and mother-in-law takes the decision to abort). One of the participant did also mention that in some cases, decision also lies with the women and her husband, by saying, “Aajkal toh naye zamaane mei toh miya biwi razi toh khud hi nirnay le lete hai” (In this modern era, couples may themselves make decisions).
The illegal practice of sex determination of the fetus in the community was confirmed by ASHA and residents of the community. A 28-year-old married female also confirmed the illegal practice of sex determination, she said, “Ultrasound 1000–2000 rupees mei krwaya ladka ladki pata karne ke liye” (just in INR 1000–2000, people get their ultrasound done to determine the sex of their child). The PNDT officer said, "To prevent sex selective abortions our office conducts 7–8 raids per month. We find quacks stealing USG machines or registering under fake names".
With regard to health seeking behavior, most people considered the doctors in government hospitals to be better healthcare providers and found these hospitals cheaper. However, they found it time consuming to avail services there. Some people preferred private practitioners due to increased sense of privacy and the fear of judgment from government employees in the government facilities (Fig. 1). A 30-year-old married female said, "Sarkari mein doctor acche hote hai aur private mein jyada paise lete hai” (The doctors at government hospitals are really good and private health services are too costly). For privacy, pregnant women prefer to travel to distant places to get their abortion. An ASHA worker said, “Chori chupe apne pihar chale jaati hai ya jamuna paar kahin karwake aa jati hai” (women secretly go to their parents’ house or go to some distant place and get their abortion done). Unmarried pregnant women preferred to go private practitioners or unauthorized places. A PNDT officer said, “Unmarried females rarely come to the government hospitals because of social stigma.” The community had a negative perception towards private practitioners due to the perceived greater amount of cost charged for provision of abortion services and indulging in illegal sex determination. Still, people consulted private practitioners due to efficient and quicker delivery of abortion service. A 29-year married female said, “Private doctor paise kha rahe hain andar hi andar” (Private practitioners are just behind money), while a 25 year old married female said, “Private mein kaam jaldi ho jata hai” (Abortion in private hospitals require less visits and the process is faster).
Facilitators and Barriers to seeking safe abortion
The facilitators to abortion included confidentiality maintaining measures, over-the-counter drugs, positive behavior from health care workers and ubiquitous health facilities. With respect to confidentiality measures “We have to maintain the confidentiality of the patient,” said the gynecologist. Easy availability of drugs over the counter was believed to facilitate abortion in the community in comparison to faith healers and unauthorized practitioners. Few participants mentioned that these drugs are given at very high costs when given without prescription in private pharmacies. According to the healthcare workers and pharmacists, these medications were not given without prescriptions due to the strict law. A MPW worker said, “Ballabgarh ke joh medical store hain woh agar likha hua hoga toh dete hain aise nhi denge, pehle toh aise hi mil jaati thi par ab aisa nahi hota” (MTP drugs were available earlier over the counter in pharmacies of Ballabgarh town, but these days, these pharmacies demand prescription before dispensing). The PNDT officer said, "People buy abortion pills directly from the chemist, often end up paying INR 1500 for a medicine costing INR 500”. Non-judgemental positive attitude not only from the doctors but also from the rest of the healthcare team was considered important. A 30-year-old married female said, “Yahan par ek madam hai, woh humari baat personally sunti hai, hume raye deti hai” (One of the health staff here is receptive to our needs and provides personal advice accordingly).
Private facilities though expensive were preferred due to their ubiquity, ease of access and confidentiality. An MPW worker said, “Humare hospital main toh hota nahi hain, government ke liye Ballabgarh main jaana padta hain, baaki private main ho raha hain” (Abortion services are unavailable in the government facilities of the village. To avail abortion facilities from a government institute, they need to go either to the high centers in the town. While in private health facilities, these options are ubiquitous). A 25 year old female said, “private me jaake kara lete hain, angrezi dawai le lete hain” (People visit private facilities to get an abortion, they easily get MTP drugs there).
The barriers to safe abortion identified include social stigma, improper staff behavior and delay at government hospitals, lack of privacy at government hospitals, myths regarding its consequences, laws and guidelines, high cost at private health facilities, and lack of infrastructure at rural areas. The sarpanch said, “sarkari aspatal mein bahut sunate hai, bahot ghumate hain'' (Government hospital staff members scold the patients and keep delaying the service). A 32 year old married female said, “ “vaha jaenge to aaj nahi hoga, wahan time dedete hain aage ka”(in the government hospitals, they don’t treat on the same day, they always ask to come on a later date) while a 29 year old married female supported and said, “ye to koshish hi nahi karte, direct hi refer kar dete hain”(they don’t even try to help, they refer to higher centers directly). A 29-year-old female said, “Dar ke maare nahi aate. Kisi ko pata chal gaya toh? (they are afraid, what if someone finds out?)”. Social stigma and widespread unacceptance of abortion as a healthy and necessary procedure in the society led to reluctance of many pregnant females, especially unmarried females to seek safe and legal abortion to avoid being defamed in their own community. A 37-year-old married female said, “badnami hoti he” (it is a disgrace).
Myths regarding abortion and its consequences such as infertility were also prevalent in the community which led to unwarranted phobia among the community regarding abortion, causing fewer people needing abortion to consider it. A 31 year old married female said, “Aaj ultrasound karwake baccha gira diya, but kal baccha ho paaye nahi ho paaye kya pata (carrying out an abortion after ultrasound today, may limit their ability to have children in the future)” while a 25 year old married female said, "Isme toh haani hi haani hai, aage jaake baccha paida nahi hota“ (abortions can cause infertility).
Various laws and guidelines of the government with otherwise good intentions and implications cause untoward phobia and unnecessary difficulties for abortion seekers in the community at both the clinical and paraclinical levels. Healthcare professionals and staff are scared themselves in aiding abortion as it may lead to an untoward legal action. A 25 year old married female said, “har koyi darta hai, ki humpe case na ban jaye” (everyone is afraid of legal action against them). The PNDT officer said, "Doctors are scared because their records may be incomplete even if they are not doing anything illegal”.
Lack of transport services make healthcare less accessible in the peripheries. Comparatively inferior technologies and expertise in government establishments is causing people to rely more on private establishments or avoid seeking healthcare in the first place. Lack of affordability at private establishments and the other stated problems faced at government centers lead to a profound dilemma in these abortion seekers. Scarcity of specialists trained with abortions was also found to make abortion seekers reluctant about their decisions. An ASHA worker said, “sarkari main kuch bhi suvidha nahi milti hum toh private main hi karwayenge direct, yahi bolte hai sab” (There’s no abortion facilities in government hospitals, we ask patients to directly go to private clinics). A 45 year old married female said, “Koi suvidha nahi hai, district hospital jana padhta hai” (There are no facilities here, we need to go to district hospitals) while a 31 year old married female said, “Yahan ultrasound hai nahi. Yaha bahut checkup nahi hota” (There’s no ultrasound facility here. We can’t even get our regular check-up here). A 47 year old married female said, “Hum toh gareeb hai. Hum toh saare cheezon ke liye sarkari aspatal mei hi jaate hai aur wahan toh nahi hota” (we are poor, we can only afford to go to government hospitals, but no facilities are available there).