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Indian Journal of Community Medicine

Abortion Scenario of Adolescents in a North India City - Evidence from a Recent Study

Author(s): Sonia Trikha

Vol. 26, No. 1 (2001-01 - 2001-03)

Deptt. of Obstetrics & Gynaecology, General Hospital, Chandigarh

Abstract:

Research question: What is the actual scenario of abortions amongst adolescent girls?

Objective: To explore the socio-behavioural context of abortion in the adolescent girls.

Study design: Cross-sectional.

Setting: 9 recognised and 5 unrecognised MTP centres in Rohtak city.

Participants: Adolescent girls (10-19 years) seeking abortion services.

Sample size: 83 adolescent girls, out of which 75 were unmarried.

Study variables: Age, literacy, rural, urban, marital status, awareness level, safe sex, facility used.

Results: 75(90%) out of 83 adolescent girls undergoing abortions included in the study were unmarried. More than 50% of unmarried girls had a friend or fiancee 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 centres 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 use.

Keywords: Teenage abortions, Adolescent girls, Medical termination of pregnancy (MTP), Sex partner, Age at sexual initiation, First confidant, Contraceptive awareness

Introduction:

Adolescence, the second decade of life, marking the transition from childhood to adulthood is an important crossroad in everyone's life. Today, approximately one-fifth of the world's population is that of adolescents (10-19 years of age), 85 percent of them in developing countries1. There are an estimated 200 million adolescents in India, comprising over one-fifth of the entire population.

Whatever studies are available suggest that despite the general censure of premarital sex, a considerable number of adolescent boys (16 to 14%) and girls (1 to 10%) engage in premarital sexual activity. Various knowledge, attitude and practice studies bring out disturbingly low level of contraceptive awareness among adolescents2.

About 10 to 15 percent of the total births in the world (about 12 to 18 million a year) take place among teenage mothers3. The UN demographic data indicates that in many of the developing and industrialised countries, births to women under twenty years of age represent a growing proportion of all births4. Adolescent abortions are estimated to be upto 4.4 million per year, most of which are unsafe because of being performed illegally and under hazardous circumstances by unskilled practitioners5.

Also, there is hardly any official data or authentic research based information regarding incidence of abortions among unmarried adolescents in India2. Despite its legality, the abortion by an unmarried girl is regarded as immoral and, therefore, her search for an abortionist is stressful. Very often the confidentiality considerations over weigh the safety considerations in selecting the health facility leading such teenagers to unauthorised providers for a clandestine abortion.

This paper attempts to look at the socio-behavioral context of the abortion experience of adolescent girls by utilising data from a recent study conducted at Rohtak - a district headquarter town of Haryana. This study was an attempt by the author, a gynaecologist to use an innovative research design to investigate abortion situation among adolescents. It attempted to collect some basic authentic data about this very private, sensitive and neglected area. It attempted to explore if the proven sexually active girls were aware of the concept of safe sex and also how these girls coped with pregnancy and abortion.

Material and Methods:

Haryana is an economically advanced northern state of India. Despite its economic prosperity its overall social indicators are poor. For instance, Haryana has the fourth highest (Rs. 3,685) per capita income in the country. In the mid-nineties its poverty index was 21.5%, whereas that of India was 36%. Life expectancy is 65 years in Haryana in comparison to the all India average of 59 years. In contrast, it had the nation's lowest sex-ratio of 865 as per 1991 census. Its Human Development Index is 50, Gender Index is low at 54 and Reproductive Health Index is 46. Girls are married at a relatively early mean age of 19.2 years6.

Data for the current study was collected in Rohtak city. It had a population of 2,16,096 as per 1991 census, a growth rate of 29.58% and a sex-ratio of 884. As per the Rapid Household Survey conducted by Indian Institute of Health Management and Research, Jaipur in Feb, 99 for the RCH project7, mean age at marriage for girls who got married between 1995 and 1998 in the district was 18.5 years. As per this survey, 100% induced abortions since 1.1.1995 had been conducted by qualified doctors. There are 20 recognised Medical Termination of Pregnancy (MTP) centres in the city including the ones at the Medical College Hospital (the only one in the State) and the Civil Hospital. MTPs are also performed at 21 other centres which are unrecognised but whose existence could be found easily by talking to a few key informants.

The area of operationalising the study was Rohtak city. The sites of study were the abortion facilities located in the city. The sample, however, was not confined to urban respondents as these facilities had rural clientele as well.

Due to the sensitive nature of the research being conducted, it was decided to elicit information from respondents at the site of medical termination of pregnancies rather than sampling adolescents in any of their social setting. This required the participation and support of practitioners providing MTP services. In order to involve the practitioners, the author individually contacted all the health practitioners in the city who perform MTPs and explained the purpose of conducting such a study.

1st Session:

The entire universe of 39 private practitioners (qualified and unqualified) were then invited to participate in a discussion session in order to finalise both the methodology and the issues to be investigated. 24 practitioners participated in the session where a presentation was made on "Adolescence - Transition from childhood to adulthood" in which various psychological, physical, behavioural, social and emotional changes associated with this age period were discussed. The tendency of experimentation characteristic to this period, which could result in disastrous consequences ranging from school/college dropout, drug addiction, emotional/nervous breakdown to indulgence in unsafe sex leading to sexually transmitted diseases and unwanted pregnancy, was highlighted.

It was finalised that only those adolescents undergoing MTPs would be included as respondents, who gave their informed consent for the interview. The respondents were to be assured of maintenance of complete secrecy, confidentiality and anonymity of the interview. The first draft of the questionnaire was circulated for pre-testing. Those willing to participate in the study were invited to attend another session a week later.

2nd Session:

Fourteen practitioners attended the second session. Seven of them had Post Graduate degrees, four were MBBS/BAMS and three were RMPs. The draft questionnaire circulated in the previous session was discussed threadbare. The language, content and sequencing of a few questions were modified on the basis of suggestions. Complete secrecy regarding the identity of respondent teenager and the practitioner performing termination of pregnancy was promised.

It was decided that two methods for collecting information would have to be followed depending upon the literacy level of the respondent. A questionnaire would be provided to the educated respondents. For the rest, information would be drawn verbally. Either the author or the practitioner performing the surgical procedure would later fill up the questionnaire of such a respondent immediately after she had left the health facility. The quality testing of information elicited by practitioners would be done randomly, whenever required.

The sample was purposive and included only those adolescent girls who were undergoing MTPs. No other controls on the sample were maintained.

From March 1, 2000 to July 31, 2000 the author and the participating practitioners interviewed 83 adolescent girls who underwent abortions. The abortion clinics where questionnaires were filed up were both recognised and unrecognised centres for MTP. 38 respondents were interviewed at 3 unrecognized centres manned by RMPs, 9 at 2 unrecognised clinics of BAMS doctors, 30 at 7 approved centres of qualified gynaecologists and 6 at 2 approved clinics of trained MBBS doctors.

Results:

Of the eighty three adolescent girls, thirty six (43%) belonged to Rohtak city and forty seven (57%)had come to the city from some neighbouring village for abortion. All were within the age bracket of 14-19 years. Barring only eight (10%) cases, all others were unmarried. Twenty three (28%) of these girls had never attended school. Twenty seven (33%) had dropped out of school at primary level. Thirteen (16%) were matriculate and seven had studied upto higher secondary level. Thirteen (16%) were graduates or undergraduate students. More than half of the girls (56%) were in good general condition with a haemoglobin level of more than 10 gm%. Only one respondent was severely anaemic with Hb of 6 gm%. This particular patient, an illiterate 16 years old urbanite, underwent second trimester abortion as her husband was seeking divorce.

The major findings of the study relevant to sexual behaviour, awareness on STD, AIDS and contraception and coping with the problem are presented hereunder:

Table I: Age at sexual initiation.

Age (years) No. n=81 (%)
14 2 (2.4)
15 19 (23.5)
16 14 (17.3)
17 12 (14.8)
18 21 (25.9)
19 13 (16.1)

Excluding the two girls who had become pregnant as a result of rape, information about age at sexual initiation of the eighty one respondents is set out in Table I. A considerable proportion (43%) of these girls had become sexually active by the age of 16 years. The youngest age at which sexual intercourse was reported was 14 years. Another 40% were sexually active by the age of 18 years.

In a vast majority (42%) of cases, it was friendship that had led to sexual relationship. Incestual relationships resulted in pregnancy in around 16% cases. One case each was reported where sex partners were father and brother. Thirteen (16%) girls were engaged to be married to their sex partners. Of the 8 married women included in the study, 6 reported their husbands as their partners, indicating the presence of extra marital relations. While most of the girls who chose "Any other" did not elaborate, a few described him as teacher, tenant and neighbour. In one case, identity of the partner was not known as the woman was allegedly drugged and raped.

Table II: Age of partner.

Age (in years) n=83
No.
(%)
Not known 1 (1.2)
14-19 25 (30.1)
20-25 49 (59.1)
26 & above 8 (9.6)

As can be inferred from Table II, most of the partners responsible for the pregnancy were either adolescent boys or very young men. The sugar-daddy phenomenon of African cities8 is clearly non-existent. It is worrying that a significant number (30%) of the partners indulging in unprotected sexual behaviour were adolescent boys too young to own responsibilities.

Eight respondents (9.6%) were undergoing abortion for the second time and for another respondent, it was her third abortion. Two of these 9 girls were married. It is disturbing that 7 unmarried girls had unprotected sex even after having experienced an unwanted pregnancy and an induced abortion. The rest of the girls (89%) were undergoing abortion for the first time.

Table III: Awareness regarding STDs & AIDS vis-a-vis literacy status.

Literacy status Awareness
Regarding STDs Regarding AIDS
Aware % Not aware % Aware % Not aware %
Illiterate (n=23) 0   23 (100) 0   23 (100)
Primary (n=27) 5 (18.5) 22 (81.5) 11 (40.7) 16 (59.3)
Matric (n=13) 5 (38.5) 8 (61.5) 8 (61.5) 5 (38.5)
Higher Secondary (n=7) 5 (71.4) 2 (28.6) 7 (100) 0  
Graduate (n=13) 11 (84.6) 2 (15.4) 13 (100) 0  
Total (n=83) 26 (31.3) 57 (68.7) 39 (47) 44 (53)

Figures in parentheses indicate percentages.

Correlation between education status and awareness regarding STDs and AIDS was found to be strikings as all illiterate girls were unaware of both STDs and AIDS, whereas, all graduate girls or the ones doing graduation were aware of AIDS and 85% of these girls were aware of STDs. It was found that level of awareness progressed with education status. Only around 19% of girls who had studied upto primary level had heard about STDs and 41% of such girls had heard about AIDS. Around 39% and 62% of girls who had studied upto tenth standard were aware about STDs and AIDS respectively. Around 71% of girls who had studied upto Plus-2 level had heard about STDs, whereas, all such girls were aware regarding AIDS.

Contraceptive knowledge among the rural girls was found to be lower as compared with urban girls. Out of all urban girls, 80% and of all rural girls around 66% were aware regarding some contraceptive method. Overall, 72% of respondent girls were found to be aware of at least one contraceptive method and around 28% did not know about any method of contraception.

Of the 60 respondent girls who were aware of at least one method of contraception, only 1/5th actually tried to have protected sexual intercourse. Of these, around 3% girls were on contraceptive pills, albeit irregularly and in 17% cases, the partners used condoms as contraceptives. In 80% cases, sexual relations were unprotected, the girl's awareness of contraceptive methods notwithstanding. This is indicative of risk behaviour of a very high degree.

Table IV: Persuasion of partner regarding use of condom vis-a-vis awareness regarding STDs, contraception and marital status:

Persuasion Awareness Marital status
As Contraceptive Measure Regarding STDs Regarding AIDS Married Unmarried
Aware (n=52) Not aware (n=29) Aware (n=24) Not aware (n=57) Aware (n=37) Not aware (n=44) (n=8) (n=75)
Yes (n=11) 11 (21) -   8 (33) 3 (5) 10 (27) 1 (2) 4 (50) 7 (9.3)
No (n=70) 41 (79) 29 (100) 16 (69) 54 (95) 27 (73) 43 (98) 4 (50) 68 (90.7)

Figures in parentheses indicate percentages.

Excluding the two cases of rape, of 81 respondents, only around 30% girls, who were aware of STDs, AIDS and prophylactic use of condoms against these diseases, persuaded their partners to use condoms. The rest were indulging in unsafe sexual behaviour despite being aware regarding STDs including AIDS. Also, amongst the ones who were aware of the use of condom as a contraceptive measure, only 21% had asked their partners to use it.

Surprisingly, only 9% girls from amongst the 75 unmarried in the study group, persuaded their partners to use condoms, whereas, 50% of married girls did so.

Excluding the four girls who remained ignorant of their pregnancy till some family member raised a doubt, close to half the girls (46%) shared the suspicion of pregnancy with their partner. In 30% of cases, it was the mother with whom information was shared first. Around 15% girls confided in their sisters or any other relative. Around 4% girls told their friends first about their suspicion. None of the girls mentioned it to any male relative.

Location of the abortion facility being away from home and, therefore, chances of confidentiality being ensured was the most significant factor, considered by around 47% girls while deciding where to go for an abortion. Efficiency/reputation of the health care provider was considered important by only around 19% of respondents while making decision regarding a particular abortion facility. A major portion of the study sample (42%) chose a particular place only because other clinics could be far more expensive.

Only one respondent, who was married, had chosen a place that was near her residence.

Table V: Person accompanying at health facility (%).

Person As first
confidant
As information
provider about
health facility
Accompanying
at the
facility
Partner 46 36 26
Mother 30 24 40
Relative 15 8 22
Friend 4 16 8
Doctor 5 - -
Any other - 16 -
None - - 4

40% of girls seeking abortion were accompanied by either their mother or father or both at the abortion clinic. Around 26% of girls were accompanied by their sex-partner, 22% by some relative and around 8% by a friend. 4% girls reported to the health facility for abortion unaccompanied by anyone. The traditional role of mother as the most important supporter in troubled times clearly continues even as more and more adolescents secretly indulge in sexual experimentations.

In around 55% of cases, pregnancy was terminated in 1st trimester while in 42% cases, termination of pregnancy was performed in 2nd trimester. Two respondents reached a health facility only in the 3rd trimester of pregnancy and were advised to carry on with the pregnancy till term after a complete antenatal examination was carried out by the concerned practitioner.

Discussion and Conclusions:

The incidence of abortion among adolescents in Rohtak is indeed alarming. 75 unmarried and 8 married adolescents sought abortion in five months (March-July, 2000) at one third of the MTP centres in the city. This would average to an annual figure of around 600. At this average number of abortions being performed annually on adolescents in various towns of Haryana, by guess is estimated to be at least 10,000. During the period under study the government MTP centres reported only 5 cases of adolescents abortion, all of whom were married (not included in the present study). The 1997-98 Year Book of the Family Welfare Programme in India puts the annual number of adolescent abortions performed all over Haryana at only 55810. Thus, the official data is able to represent only the tip of the iceberg.

In this study, age of first sexual contact was predominantly found to be 16 years, though the youngest age was 14. This is not at variance with many of the cultures in the world. According to a study by the International Centre for Research on Women, a quarter of the adolescent girls in Brazil reported having first experienced sex before the age of 13, in Malawi, the mean age was 13.6 years and in Papua New Guinea the first intercourse occurred as early as 11 years of age9. Another finding of the present study has been that majority of these girls had not been coerced into sexual intercourse. As many as 65.1 percent indulged in sexual activity with the fiancee, a friend or husband. Thus, when for millions of young girls elsewhere, sex is linked with coercion, violence and abuse, the present study found that it was a case of consent, active or passive, for a vast majority of girls. Young females are prone to sexual abuse and many a times girl's first experience is a forced one. More than half the young women in Malawi study reported coercion, over 20% of the young women in Brazil and over half the young women in Papua New Guinea said that they had been coerced, often violently9. In the present study, only two cases of rape were reported.

Pre-marital sexual activity among adolescents is considerable and is not influenced by residential or educational status. More than half the unmarried adolescent pregnant girls were found to have engaged in the sexual act with a friend or fiancee. Incest is not uncommon. In 60% cases, pregnancy was an outcome of sexual intercourse with some relative. One case each was reported where partners were father and brother, which hints at immense psychological trauma that these girls may go through even later in their lives and their absolute insecurity in their own homes. Age of sexual initiation has been found to be a major factor associated with teenage abortions. Studies have revealed that those who start cohabiting at very early ages (less than 17 years) reportedly experience a greater number of abortions11. In the present investigation more than 10% of the girls were found undergoing abortions for the second or third time.

Level of awareness about AIDS (47%) among these adolescents (though still low) is more than that regarding STDs in general (30%). This may be due to the increased use of media for promotion of AIDS awareness in recent years. However, this points towards necessity of strengthening the nature of awareness campaign being carried out by the National AIDS Control Organization and its State level societies. While the outreach for AIDS awareness is considerable, the campaign has been unable to communicate that STDs themselves make an individual more prone to contracting the virus. Also 77% of the girls were of the opinion that AIDS is transmitted only through sexual contact reflecting that complete awareness regarding AIDS transmission has not yet been realised.

Despite the striking correlation between education status and awareness regarding AIDS and STDs, it is disturbing to find non-insistence on the use of condoms by the partner even on the part of those girls who were aware of the prophylactic use of condoms against these diseases. Only 9% of such girls could persuade their partners to use condoms. Even the nine educated girls intelligent enough to confirm pregnancy by self-test using card/strip method had not coaxed their partners to use a barrier method to avoid unwanted pregnancy and protect themselves against STDs. This has serious implications for the spread of STDs and HIV.

While the study did not attempt to explore the abortions being conducted in rural areas, there is clear evidence that many ruralites are reaching the town in search of abortion facilities. More than half the abortions were performed on rural girls not residing in the city. This could be explained by the lack of confidentiality and a general low standard of health care provision in villages, more so with regard to MTP services Dr. N. Phanindra Babu et al had also found a higher incidence of induced abortions in urban areas than in rural areas in their study which was conducted on the basis of NFHS data11. However, it may not be correct to explain this rural urban differential on the basis of differences in social and cultural norms affecting the behaviour of women, more so in the case of unmarried adolescents. Further, there is sufficient evidence that sexual activity among unmarried adolescents in rural areas is not as uncommon as is often believed. Lower levels of awareness regarding STDs, AIDS and contraceptive measures among rural girls compared with urban girls were also brought to the fore.

Adolescent girls are much more likely than older women to delay seeking abortion services and, therefore, undergo second trimester abortion12. The FWPI Year Book for the year 1997-98 reports only 6.6% of all abortions performed in Haryana to be conducted in second trimester10. In the present study 42% of the adolescents underwent MTP in second trimester. This implies serious medical repercussions for adolescent girls especially when seen with the fact that 56% of these abortions had been performed at unrecognised centres by inadequately trained personnel.

Once they became pregnant, nearly one-third of these girls had the courage to share the fact with their mothers first. Younger ones were more likely to do so and in a still larger number of cases, parents accompanied the pregnant girl to the health facility. A clear case is thus made out for empowering mothers to act as providers of `Family Life Education'. Also effective family life education programmes must be instituted for adolescents (both school going and out of school ones). These programmes must give correct information to the adolescents about reproduction and contraception.

As mentioned earlier, during the time span of the present study no unmarried adolescent girl's abortion was reported officially at any of the Government hospitals including the Medical College Hospital in the city. A considerable number (46%) of cases were performed by RMPs having no medical background. Confidentiality and procedure's cost considerations were given more importance than safety consideration by these respondents. It was practically not possible to follow-up each teenager girl to know if she developed any post abortal complications. However, during the study period, seven cases of `septic induced abortion' were reported at the Medical College Hospital (the only likely place where serious and complicated cases would be referred to) of adolescent girls belonging to Rohtak district and two of these cases were of unmarried adolescents. This brings out the need for encouraging doctors and paramedical staff at Government Hospitals and MTP centres to adopt more empathetic and respectful approach towards adolescents to enable them to avail of less expensive and safer health services.

References:

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  2. Jejeebhoy SJ. Adolescent Sexual and Reproductive Behaviour. ICRW Working paper 1999: 8-20.
  3. Eckholm E, Kathleen N. Health - The family planning factor. Population Reports 1997. Series J, No. 14.
  4. Irving S, Wells C. Pregnancy in adolescence: Needs, problems and management. New York: Van Nostrand Reinhold Co.; 1982.
  5. Population Reference Bureau and Centre for Population Option: facts at glance. New York: 1994.
  6. Lal S. Research Priorities in Reproductive and Child Health. Indian Journal of Community Medicine. 2000; 25(2): 51.
  7. Indian Institute of Health Management Research, Jaipur, Rapid Household Survey - RCH Project 1998: 10 (February 1999).
  8. Leshabari MT. Factors influencing school adolescent fertility behaviour in Dares Salaam [Thesis], Tanzania. Baltimore. Johns Hopkins University Baltimore: 1988.
  9. UNAIDS. Force for change: World AIDS Campaign with youth people. World AIDS Campaign Briefing Paper; 1988.
  10. Govt. of India. Family Welfare Programme in India, Year Book 1997-98. New Delhi: MOHFW; 1998. p.137-8.
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  12. Chhabra S. A step towards helping mothers with unmarried pregnancies. Indian Journal of Maternal and Child Health 1992; 3(2): 41-2.
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