Introduction

Abortion has been legal in India for over four decades. The Government of India’s Medical Termination of Pregnancy Act, 1971, allows women to undergo abortion up to twenty weeks of gestation in a broad spectrum of conditions including contraceptive failure.[1] To expand availability, India’s National Population Policy envisaged the provision of abortion services in all public primary health facilities to individuals with pregnancies of up to eight weeks’ gestation.[2] Despite these policies, access to safe abortion services in facilities remains elusive for many in the country for barriers such as cost, lack of trained providers, physical accessibility of clinics, stigma, and misconceptions surrounding the legality of the service.[3] A 2015 study found that only 24% of primary health centres in Uttar Pradesh provide either abortion or post-abortion care, and most public facilities offering related services (64%) only offer post-abortion care.[4] Additionally, while the majority (74%) of women in Uttar Pradesh live in rural areas, only 39% of all facilities, private and public, which offer abortion-related services, are based in these areas.[4]

In 2002, the Drug Controller of India approved medication abortion (MA) using a combined regimen of mifepristone and misoprostol as an accepted abortion method.[5] This led to widespread and convenient availability of MA combination packs, or “kits,” in pharmacies across the country, even both drugs are under Schedule “H” in the country, not to be sold without prescription. In 2010, the Government of India further issued guidelines to train doctors in public health facilities on comprehensive abortion care, including both medication and surgical abortion. Though the government has taken progressive steps to increase access to legal and safe abortion services by amending policies in response to the changing abortion landscape in India, maternal mortality attributable to abortion-related complications remains high, accounting for an estimated 9% of maternal deaths in the country.[6] While many of the efforts to improve the quality of abortion services has focused on health facilities, data shows that individuals are increasingly purchasing MA kits directly from pharmacies, often without prescription. In addition to its widespread availability, the low cost of the medication compared to seeing private providers and the fact that MA, which studies suggest may often be preferred over surgical abortion, is frequently unavailable in public facilities, may be aiding the popularity of this practice.[7–9] In a recent study on abortion incidence, of the estimated 15.6 million abortions that took place in India in 2015, 81% (nearly 12.7 million) were estimated to have been done using MA. Almost three fourths (73%) of all abortions were through MA pills taken outside of facilities, possibly without medical advice or supervision.[10] Uttar Pradesh’s percentage is even higher; 83% of the estimated 3.15 million abortions that take place annually in the state are through out-of-facility MA use.[4] Due to gaps in pharmacist knowledge and little widely accessed information on the products, many individuals consume MA without complete knowledge on dosage, normal side effects, and possible complications.[11–15]

Uttar Pradesh (UP), India’s most populous state, performs poorly in most maternal and child health indicators, including low uptake of family planning and one of the highest maternal mortality ratios in the country. [16,17] According to the fourth National Family Health Survey (2015–16), the total unmet need for family planning in UP was high at 18.1%, with fewer than half (45.5%) of married women of reproductive age reporting current use of any family planning method, and less than a third (31.7%) using a modern method. [16] MA kits in UP, as in much of India, are widely available in pharmacies. Studies from other Indian states have reported that many pharmacists were providing MA kits readily without prescription and were either sharing inaccurate or no information while dispensing the MA kit to users. [11–15]

While studies exist that explore pharmacist knowledge on MA in India and their provision of the drugs, limited research, particularly qualitative research, explores pathways to out-of-facility MA use from the client’s perspective, despite its increasing popularity. A 2004 household survey on “Unwanted Pregnancy and Induced Abortion” in Rajasthan, surveyed women and men with a quantitative tool on their abortion experiences and knowledge and collected some information on abortion seeking pathways.[18] Twenty percent of women in the study who reported successful abortions said they had tried aborting on their own or went to an informal provider (n = 41). While two thirds of the women who attempted self-managed abortion had complete abortions, one third were unsuccessful, and ended up seeing an average of 1.1 formal providers to complete termination. A more recent study exploring the pathways to unsafe abortion in Madhya Pradesh, which employed both quantitative and qualitative methods, found that over half (53%) the women recruited in five government-run medical college hospitals and five district hospitals first attempted to abort at home, and 85% of those with “tablets.”[19] Additionally, 90% of the study participants who experienced post abortion complications first visited one or more local providers before seeking care at a district hospital or medical college, and 68% initially sought care from uncertified providers, like pharmacists. Another study in Bihar and Jharkhand found that 31% of women surveyed for eligibility for the study made at least one unsuccessful attempt to terminate a pregnancy by using medications or preparations at pharmacies before seeking care at a clinic.[20] While demographic characteristics of those who had attempted abortion before presenting to the health facility were examined, the study did not collect information on decision-making pathways or in-depth experiences with self-managed abortion.[20] Two other relevant studies in India examined women’s perspectives of and experiences with MA in clinics, but did not recruit women who had pursued out-of-facility abortion.[21,22] Qualitative studies with men on their experience as part of the out-of-facility MA decision-making process do not appear in the extant literature, despite evidence that they often purchase MA at pharmacies for their partners. [13–15]

In this context, qualitative research was conducted in UP, India, with the objective of tracing the decision-making pathway(s) of women and men seeking MA services. The goal of this study is to understand the gaps in knowledge and behaviour in depth, and the complexities of decision-making for the people who are actually purchasing MA and thus make recommendations for higher quality person-centred abortion care.

Materials and methods

A total of 40 in-depth interviews (IDIs) were conducted with recent MA users in three districts in UP, India—the state capital Lucknow and two adjoining districts of Kanpur Nagar and Unnao. Twenty IDIs were conducted with clinic and 20 IDIs with pharmacy clients/users and/or their partners (both men and women). Of the total respondents, 20 were users and 20 were partners. Interviews were conducted by a team of experienced Indian qualitative researchers with a background in social science and public health.

The IDI guides for men and women who had purchased MA from a pharmacy or visited a clinician for MA covered the source of the user’s knowledge of MA, pathway of accessing it, nature of interaction with the provider and information received, experience after taking MA, barriers to obtaining care of desired quality and suggestions for information and support required for MA. All IDI guides were developed in English, translated to Hindi and then back-translated to check for consistency.

To recruit participants, we enrolled MA providers in collaboration with an international organization that manufactures and sells MA kits to pharmacists and clinics. The international organization shared a list of pharmacies and clinics who had purchased MA kits from them and who were likely to respond positively to the study. The shortlisted providers were then approached at their shops/clinics and requested to participate in interviews for another part of the study (not reported on here).

After the interview with the provider, they were requested to share contacts of clients for the interview of MA users, with the client’s permission. Clients who had used MA were contacted, asked to participate, and if interested, we set up a time for the interview. Interviews were conducted in a private place chosen by the respondent, and ranged from their home, the clinic itself, restaurants, cafes, malls or the survey team’s vehicle. A few interviews were also conducted telephonically. Verbal informed consent was obtained from the MA users before the interview. The interviews were conducted in Hindi and audiotape recorded. Once MA users were contacted and interviewed, further users to be interviewed were also identified through the snowball method by asking them to share contact details of any acquaintance of theirs who had also recently used MA services from a pharmacy or clinic. The interviews lasted for about 30–45 minutes. Ethical approval for this study was obtained from the University of California, San Francisco (153312) and the Institutional Ethics Committee of the Public Health Foundation of India (TRC-IEC-276/15). The study received ethics committee approval for obtaining verbal consent. Verbal consent was documented in a participant log maintained by the study team. Verbal informed consent was obtained from all participants for conducting and recording the interview.

IDIs were transcribed and translated to English. A team of four researchers analysed the data thematically using the Atlas.ti software. A thematic analysis approach to coding and interpreting the data was employed.[23] An initial list of codes was developed based on the interview guides and main aims of the study. After this a subset of interviews was coded by all team members, and the team met to discuss additional codes that emerged from the data to add and previously identified codes to adjust and expand as necessary. After coding another subset of interviews jointly, the team then discussed the codebook again, and finalized the codebook before proceeding with coding all interviews.

Results

Over half of the respondents were first-time users of MA. Users’ age ranged from 20–30 years, while partners were aged between 22–34 years. All except one respondent (partner) were married. Parity ranged from 0–6, with three respondents having no children and about two-thirds having two or fewer children. Most were educated, with about three quarters having completed secondary school or above. All male partners were more educated than their female partners, while nine out of 20 users were illiterate or educated only up to the primary level. Only five respondents said that they were low income, while the rest were middle-income.

Based on the accounts of users’ experiences of MA, we have constructed a pathway of care seeking for MA, that appears strongly driven by gaps in user knowledge and awareness of MA, sometimes leading to incomplete or complications in abortions, multiple providers and time delays, and escalated user costs (Fig 1).

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Fig 1. Pathway of seeking medication abortion care in Uttar Pradesh, India.

https://doi.org/10.1371/journal.pone.0216738.g001

Discussion

Our findings suggest a general lack of awareness among users about the source, dosage, progression, and side effects of MA. This led to a dependence on the first provider they approached–in most cases pharmacists—for all information. In cases where the pharmacist provided incomplete or inaccurate information, women were at risk of taking the medications incorrectly and having little knowledge about what to expect. This reflects other studies in India that found a link between poor pharmacist knowledge and poor client knowledge. A recent study of pharmacists selling MA in Delhi found that only around 40 percent were aware of the correct dosage and administration of the mifepristone and misoprostol combination. [14] Most pharmacists were not aware of any side effects or complications and were also indifferent to the needs of clients. Most pharmacists did not ask the client’s gestational age, confirmation of pregnancy, or explain side effects or failure of MA. None of them asked any obstetric history or gave contraceptive advice. [14]

The lack of knowledge about MA creates a situation where women do not know when they are experiencing complications compared to normal side effects, or that complications could require specialized care. In a state-level study of Uttar Pradesh, researchers found that about half of individuals seeking care for abortion-related complications presented with an incomplete abortion after self-administered MA use.[4] Many of these cases, as well as those with prolonged or abnormal bleeding, likely represented a normal progression of MA and would not have needed an intervention had users been given more information on the process. Twenty four percent of all women attempting an abortion in Uttar Pradesh in 2015, about 1.22 million, received treatment for complications in a facility, a complication treatment rate higher than other South Asian countries with data on the indicator, aside from Pakistan.[4] A study conducted in the states of Gujarat and Jharkhand in India by Boler et al in 2009 found 66% of women purchasing MA directly from pharmacies reported perceived complications following their abortion [15] This study also found that poor quality information from the initial provider may lead women towards more invasive, often unnecessary procedures, such as D&C.

These findings suggest that there are information gaps at various stages in the MA pathway that need to be addressed in a user-friendly and confidential manner. There is a high dependence on informal networks (friends, relatives or colleagues) for information at all levels (what to do in case of unwanted pregnancy, whom to first approach for MA, whom to approach if there is an issue following MA kit use). While informal networks and seeking information from friends and family is common in healthcare, there is a need to have more easily accessible, correct information on a product that millions of women in Uttar Pradesh, and over ten million women in India, access each year.

This study did not find as much stigma around using MA as anticipated. Some users (especially women) sometimes sought services from a provider who was less crowded, so others could not hear, or farther from their home, so people that they knew would not see them, due to stigma about seeking abortion. However, overall, there was less stigma, which may be a result of all clients having used MA and thus having low enough stigma to be willing to seek the product.

Recommendations include the need to launch large-scale public information programmes on safe abortion care, including the gestational age in which MA kits, intended to be used up to nine weeks, are effective, where to obtain MA, the recommended regimen, possible side effects, and where to go for the treatment of complications. Furthermore, many users believed that abortion was illegal in India or were confused about the status, echoing findings in other studies.[15,18,24] This accentuates the secrecy and stigma around the process, inhibiting users from seeking timely and quality care for complications. Therefore, educating the public that abortion is legal could help reduce the stigma surrounding seeking MA amongst users. Particularly, clear distinction has to be made in the messages between MA within nine weeks of pregnancy, which is legal, and sex-determination, which is illegal in India [25].

Though gender inequality and role of women in decision-making are not the focus of this paper, the study found that a few female clients did report pressure from husbands to abort, and gender inequality in decision-making, especially about using family planning, did play into some women’s decision-making processes. Women’s low status in India generally, and lack of ability to seek health care alone or without chaperons or male support in many cases, likely limit women’s access to the MA, abortion generally, or other reproductive health options that they desire.[26,27]

As pharmacists often are the first point of care and the main source of abortion medication and guidance, they should be trained to inform customers adequately to ensure clients know what to expect when taking MA. Since potential clients seek care from providers they know, and are less likely to want to return to the same provider when issues following medication use arise, pharmacists have a natural incentive to improve their quality of care to facilitate adequate exchange of information on MA. Recent evidence from Nepal shows that training pharmacy workers led to safe and effective MA sale to almost all clients. [28] Furthermore, since for most couples the male partner is the first point of contact at the time of MA purchase, it is essential to develop information approaches or tools that can enable pharmacists to provide information to those people ultimately using the medication. In contrast to other studies that examined decision-making around abortion in India, women rarely reported undergoing abortion under pressure from their husband / partner, and therefore partners have more potential to be a source of support and information. [29] It is possible that written or pictorial information pamphlets that are provided with MA, or finding ways to engage men to ensure that they pass along accurate information to their partners, could be effective methods. A hotline for women self-managing their abortion, a model employed in other settings around the world, could be another tool directly linking MA users with support and information. The hotline could be promoted at the pharmacies through signs, on the hand-outs, or even directly on the MA kit.

This study suffers from the limitations of generalizability common to qualitative research studies. It cannot be generalized to represent the national context in India. Also, being concentrated in urban and peri-urban areas, it does not effectively capture the MA user pathway in rural areas. Despite these limitations, we upheld practices in maintaining key tenants of validity in qualitative data collection and analysis, as outlined by Maxwell (1992), including generalizability and, descriptive, interpretive and theoretical validity.[30] The multi-country nature of our team, including local Indians familiar with the context and who participate in components of data collection/supervision, helped us be able to ethically and credibly collect and contextualize our data.

Supporting information

Acknowledgments

The authors would like to acknowledge the contribution of the field data collection team, led by Dr. Pravesh Dwivedi. We would also like to thank the participants who gave us their time and shared their stories.