India’s maternal mortality rate is declining faster than the global target, and the government’s aim is to bring it down to 100 by 2020. Although the decline of maternal mortality rate has come manifolds even faster (65%) than the global decline (35%), however, India still contributes one fifth of the maternal death globally. Unsafe abortion is the third leading cause of maternal deaths in the country, contributing eight percent of all such deaths annually. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, apathy and disdain toward women. Safe abortion services should be readily available and affordable to all women. This means services should be available at primary-care level, with referral systems in place for all required higher-level care. Services related to abortion should be based on the health needs and human rights of women and a thorough understanding of the service-delivery system and the broader social, cultural, political and economic context. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live.

The Actual Scenario in India

It is estimated that 15.6 million¹ abortions take place in India every year. A significant proportion of these are expected to be unsafe.  Unsafe abortion is the third largest cause of maternal mortality leading to death of 10 women each day and thousands more face morbidities. 48.1 million pregnancies occur in India annually and about 50% of these are unintended pregnancies. Unsafe abortion mainly endangers women in developing countries where abortion is highly restricted by law and countries where, although legally permitted, safe abortion is not easily accessible. Almost three-fourth of Indian women live in rural areas. Most of the trained and certified doctors live in urban areas. There is an inequitable geographic distribution of medical doctors combined with their limited number and their inaccessibility to many health services.

Providers of Safe Abortion Services

As stated by the World Health Organization (WHO 2001), “One approach to reduce unsafe abortions and their consequences is to expand the provision of abortion services to include trained mid- level providers, or non- physicians, among those qualified to perform abortions in circumstances where abortion is legal.” This is further reinforced by the WHO 2015 guidelines on Health worker roles in providing safe abortion care and post-abortion contraception where evidence-based recommendations are provided for a range of health care providers who can effectively and safely perform various interventions for provision of safe abortion and post-abortion care.

In India a majority of population lives in the rural areas with limited access to hospitals and medical doctors. Most of the rural health facilities are staffed by midwives or other mid-level providers who are usually prohibited by law to perform many emergency medical procedures, including uterine evacuation to manage abortion complications.

Hence, it is critical to recognize this gap for expanding the skills and capability of mid-level providers to manage abortion related services through support of various stakeholders. Mid-level providers have an important role to play in the provision of health services, abortion and post abortion care in particular as:

• They can to provide high quality care often at a lower cost
• They are more likely to remain at their place of posting for a long period
• They are easily accessible in every corner of the country

Practicing mid-level providers have a strong technical skill which can easily be built upon to expand availability, accessibility and quality of early abortion care by ensuring quality training on MVA and medical abortion. As mentioned by WHO, “the term, ‘non physician’ and ‘mid – level providers’ refer to a broad range of non-physician health workers, including midwives, nurses, clinical officers, physician assistants and paramedics, among others, whose training and responsibilities differ from one country to another, but who are involved in the provision of reproductive health care of primary health care services” (WHO 2003). The 2015 WHO guideline recommends that a range of health care providers, including doctors of complementary systems of medicine, nurses and Auxiliary Nurse Midwives (ANMs), in addition to general physicians and Ob-Gyn specialists, can safely and effectively perform first trimester abortions, using either vacuum aspiration (VA)[C] or medical methods. Studies conducted in India too have found that abortion care can safely and effectively be provided by a range of providers, including nurses and AYUSH practitioners.

The 7^th competency of International Confederation of Midwives (ICM) midwives provide a range of individualized, culturally sensitive abortion-related care services for women requiring or experiencing pregnancy termination or loss that are congruent with applicable laws and regulations and in accordance with national protocols. International Confederation of Midwives (ICM) states that the midwife has the skill and/or ability to prescribe, dispense, furnish or administer drugs (however authorized to do so in the jurisdiction of practice) in dosages appropriate to induced medication abortion and perform manual vacuum aspiration of uterus up to 12 completed weeks of pregnancy. (ICM,2013).

The contribution of the nurse midwives has translated in reducing the maternal mortality globally. According to the Indian Nursing Council, there are 2053 General Nursing Midwifery (GNM) Schools and 1358 B.Sc. Nursing colleges functioning in the country with an annual in-take capacity of over 1 lakh students (approximately). However, the potential of these nurses remains untapped as indicated in the nurse population as well as the nurse doctor ratio. The ratio of nurses is 1.7: 1000 population.

Globally, there aren’t enough health care providers trained and authorized to offer abortion care where and when women need it, especially in developing countries. Evidences have shown that more nurse midwives had led to fewer maternal deaths.

Around 8 countries (3 from Asia, 4 from Africa and USA) have initiated utilizing mid-level providers as the direct provider of early uterine evacuation while another 8 countries (2 from Asia, 5 from Africa and 1 from South America) have authorized them to manage and treat post abortion complications. Bangladesh has also been training mid-level providers to use MVA for more than 3 decades. In Nepal, abortion is allowed by trained and authorized health worker and mid-level practitioners whose name is registered in the concerned professional council associated with health service. Trained and certified secondary nurse midwives and health assistants are also allowed to provide abortion care services in Cambodia.

India has already lead both task shifting and sharing in various health programmes like maternal health, family planning etc. for strengthening women’s access to comprehensive abortion care (CAC) services.  It is an integral component of the National Health Mission (NHM) and one of the concrete strategy that will accelerate expanding provider base by permitting mid-level providers for provision of CAC services.

India being better in terms of economy and available health services therefore, it is even more important to train mid-level providers and provide them autonomy for provision of safe abortion services.

Strategies to bridge the gap

• Passing the amendments to the MTP Act, 1971 and expanding the provider base.
• Training of mid-level providers to ensure they have the competencies to provide good-quality care in accordance with national standards and guidelines.
• Timely procurement and distribution of all medical equipment, drugs, contraceptives and supplies necessary for the safe delivery of services by mid-level providers.
• Appropriate pre-service and in-service training based on updated guidelines for safe abortion care for mid-level providers.
• Abortion training programmes should be competency based and conducted in facilities that have sufficient patient flow to provide all trainees with the requisite practice.
• Mid-level providers may initially need support following training to put skills into practice and a mentoring programme may be put in place after the training.
• Provision for effective implementation needs supportive and facilitative supervision and oversight.

As a public health professional and a representative of Nursing-Midwifery in India, I strongly feel the need to leverage nurse midwives and other cadres of health workers in provision of CAC services. I believe CAC Conclave offers an opportunity for diverse groups to come together and broad-base the discourse for women’s access to CAC services.

Prof. (Dr.) Manju Chhugani

Principal, Jamia Hamdard College of Nursing

Dr. Manju Chhugani is an academician and a versatile leader in the field of nursing and midwifery. She has over two decades of extensive hands-on experience in the field of maternal and child health and university teaching. She also held the office of Secretary of Society of Midwives of India (SOMI) , Delhi chapter for 8 years. She is a distinguished member of various national and international NGOs like UNFPA, UNCIEF and the C3India formerly CEDPA India.