Introduction
India is one of the few countries to legalize abortion since 1971 with the passing of the Medical Termination of Pregnancy (MTP) Act.1 However, legalizing abortion has not translated into safe and affordable abortion services. The birth sex ratio in India has been declining since the 1901 census.2, 3 Potdar et al reported very high birth sex ratio of two cities in central India in census 1991- 2001.4 Despite the attempts by government authorities to monitor radiologists and genetic laboratories, the Census of India 2011reported a dip in the child sex ratio (Figure 1) in states like Maharashtra between 2001 and 2011 (from 913 down to 894).5 The efforts taken by the social groups in the 1980s led to the passing of the Pre-Natal Diagnostic Technique Act in 19946 which was amended in 2003 and renamed the Pre-Conception & Pre-Natal Diagnostic Technique (Prevention and Misuse) Act.7
The MTP and PCPNDT Acts are very distinct in content, addressing two completely different types of facilities with no cross referencing. At the implementation level, most authorities tend to combine the two and speak of “preventing sex selective abortions”.
In India abortion services have remained predominantly in the private domain, even for women who cannot afford them because this issue is sensitive and socially stigmatizing and women choose secrecy over all else. However, rather than targeting sex determination, the authorities target abortion services. Many practitioners face negative media publicity, defamation and criminal charges. Hence, they have started turning women away not only in the second trimester but also in the first. There is paucity of data regarding the acceptance of the abortion laws among doctors performing MTPs. Doctors perspective is very important for complete success of the program, hence the study was conducted with following objectives-
Materials and Methods
Study design
The present study was designed as a cross-sectional questionnaire based study carried out in clinics of participating doctors in a district in tribal region of central India. The sex-ratio of past five years will be extracted from the sources like census of India. A block wise exercise will be undertaken to map the registered private medical practitioners who are authorized to provide abortion services.
Study site and study duration
The study was conducted under the department of Obstetrics and Gynecology, Government medical college, Gondia for the duration of two months between the 1st may to 30th June 2020.
Sampling and sample size
The study participants will be selected by the stratified random sampling amongst the registered private gynecologist. Since the study is exploratory involving the sample size of 50 participants.
Ethics and consent
Participants have explained the nature of the study, and informed about their concealed identity and voluntary participation. Written Informed consent was sought and face to face interviews were conducted with those who agreed to participate.
The prior permission of Institutional Ethics Committee (Reg. no. ECR/1033/Inst/MH/2018) was taken for conducting the study.
Inclusion and exclusion criterion
Prior appointment of the busy practitioners was taken and after taking a detailed history about demographics of gynecologists, their qualification, years of experience, the gynecologists who agree to participate will be included in the study. And those who are not willing to participate or unable to give consent or those who are not registered as a gynecologists was excluded from the study.
Data collection procedure
After explaining the study protocol the participants were subjected to study questionnaire.
Study tools
In the study the self developed, pre-validated, semi-structured questionnaire which consists of both open and closed ended questions was used as a study tool.
The questions were framed to obtain information about the respondents knowledge of abortion laws and their perspectives as well as experiences of doctors regarding these relevant laws in their practice. Respondents were also be allowed to offer their suggestions /remarks apart from answering the questions.
The questionnaire was first pre-tested in five participants and suitable modifications was done accordingly.
Designing of study questionnaire
The study questionnaire was divided in three sections demographics, knowledge and perspectives.
The knowledge section has included overall 11 questions including 4 yes/ no type, 4 open ended and 3 multiple choice question using these questions the awareness of the practitioner regarding the act, its publishing year, source of the information, the formalities and documentation has been assessed.
The perspectives of the gynecologists will be noted down using 8 sub questions in which the case scenarios will be presented and the views and opinions of the gynecologists will be noted down in some yes/ no type of questions.
Statistical analysis
At the end of study, the knowledge of the participants was assessed and the perspectives was expressed in descriptive manner. The data entered into an electronic database using the MS excel 2010. Data was exported from the questionnaires and prepared for analysis. Answers were recorded and means and percentages were calculated.
Results
Demographically majority of the respondents were female and belongs to the age group of 31 to 50 years. 52% respondents have completed their DGO followed 24% completed MS, and 20% respondents were basic MBBS graduate.
52% respondents have experience of 1 to 5 years and rest of the respondents are mainly seniors and are well experienced in their practice.
Knowledge
Majority of the respondents were aware about the MTP(100%) & PCPNDT(84%) Acts. 96% of the respondents have knowledge about the year of amendment of MTP Act.
And 68% respondents said they have acquired this knowledge from their UG/PG studies but for 28% doctors government publications and for 4% doctors the media was the source of information.
Only 72% respondents said they are aware of the recent amendments in both the laws but surprisingly only 54% participants have successfully enumerated them.
Also 28% participants were unaware of the recent amendments in the Act.
Perspectives
The perspectives of practitioners were noted on the basis of open ended questions, and presented in the table no 4 to 6. Only 24% participants said that the recent amendments was very good, 12% said that they were necessary but still 12% doctors believed that there is a scope for further amendments in the Act.
According to 64% participants the PCPNDT Act is acceptable but 12% said record keeping is very difficult and 6% felt that it needs lots of amendments.
When asked about the abortion in unmarried girls, 84% felt that this act protect her from harassment but surprisingly 12% respondents felt that abortion of unmarried girls will create problems for them and 4% them did not responded to the question.
76% gynecologists have opinion that couples should not be permitted for gender determination, 16% gynecologists said it should be the right of couple and 8% doctors said the only couples already having 3 or 4 child should be permitted for gender determination.
Table 1
Demographics of the participants
|
Category |
Number of participants (n) |
|
Age |
|
|
21-30 |
12 |
|
31-40 |
18 |
|
41-50 |
18 |
|
>50 |
02 |
|
Gender |
|
|
Male |
10 |
|
Female |
40 |
|
Educational Qualification |
|
|
MBBS |
10 |
|
DGO |
26 |
|
DNB |
02 |
|
MS |
12 |
|
Total |
50 |
Table 2
Experience of practitioners in years
|
Experience of practitioner(Years) |
Number of participants (n) |
|
1-5 |
26 |
|
6-10 |
08 |
|
11-15 |
06 |
|
16-20 |
02 |
|
21-25 |
08 |
|
Total |
50 |
Table 3
Knowledge of practitioners about the abortion laws (n=50)
Table 4
Perspectives on MTP Act 1971
Table 5
Perspectives on PCPNDT Act
|
View |
Number of respondents |
|
Acceptable |
32(64) |
|
Difficult to fill F form |
02(04) |
|
It has increased corruption |
04(08) |
|
Record keeping is difficult |
06(12) |
|
It needs lots of amendment |
06(12) |
Table 6
Opinion of practitioners on the future aspects of abortion laws
Discussion
The obstetrics & gynaecology is a unique and complicated. This branch is different from the general medicine because of the various physiological changes in pregnancy and also because this is associated with the various legal aspects like MTP and PCPNDT Act. and only an experienced OBGY professional who has good knowledge of OBGY and legal aspects of medicine can interpret, understand and perform various surgical procedures like medical termination of pregnancy.8
The Government of India have approved MTP Act in 19719 and PCPNDT Act in 1994 and recently in 2020 Government of India given amendments in the MTP Act.10 but there was paucity of data regarding the acceptance of the abortion laws among doctors performing MTPs. But doctors perspective is very important for complete success of the program.
In the present study, nearly all the respondents were aware about the MTP(100%) & PCPNDT(84%) Acts. and 96% of the respondents have knowledge about the year of amendment of MTP Act.
68% respondents said they have acquired this knowledge from their UG/PG studies but for only 28% doctors government publications and for 4% doctors the media was the source of information. Hence, there is a need to improve the awareness about the laws and their recent amendments from the government circulars and CME's.
Only 72% respondents said they are aware of the recent amendments in both the laws but surprisingly only 54% participants have successfully enumerated them and 28% participants were unaware of the recent amendments in the Act.
84% practitioners provide only first trimester abortions because mainly they are not aware about the paper formalities and documentation procedures of second trimester abortions.
In the present study, only 24% participants said that the recent amendments was very good, 12% said that they were necessary but still 12% doctors believed that there is a scope for further amendments in the Act.
One of the gynecologist said that "Abortion or Medical Termination of pregnancy ACT of 1971 should allows a pregnant women or a girl irrespective of her marital status to have choice of either to go ahead with the birth or terminate the pregnancy." this will be good for the unmarried mothers.
Other gynecologist said that "MTP should be a choice of couple, especially mother(no condition shall be applied to deny termination of the pregnancy except medical)."
Another 45 years old and a gynecologist with 15 years experience said that "There is no need of limitation of gestational age for abortions in case of anomalous baby, because many anamolies can be detected in the late pregnancy and that time we are in pressure of laws whether to do MTP or not but for such cases there should not be any limits."
12% respondents said that there is a need of amendments in PCPNDT Act and the law should not point out the gynecologists.
Majority of the gynecologists feel that there is need of increasing abortion centers with trained gynecologists and they should be trained about the legal aspects of MTP Act.
84% respondents felt that the abortion in unmarried girls protect her from harassment but surprisingly 12% respondents felt that abortion of unmarried girls will create problems for them and 4% them did not responded to the question. Hence, there is a need of clear guidelines for the abortion in unmarried girls.
About the PCPNDT Act some gynecologists said that it should be the right of couple and some doctors said the only couples already having 3 or 4 child should be permitted for gender determination.
From our study we can say that the abortion law are good but there are some loop holes and they need to be corrected taking in consideration the perspectives of the gynecologists because they are the grass root people performing the actual procedures and facing the routine cases.
Conclusion
From the findings of the present study, we can conclude that-
Majority of the respondents were aware about the MTP(100%) & PCPNDT(84%) Acts.
68% respondents said they have acquired this knowledge from their UG/PG studies but for 28% doctors government publications and for 4% doctors the media was the source of information.
Only 72% respondents were aware of the recent amendments in both the laws but surprisingly only 54% participants have successfully enumerated them.
28% participants were unaware of the recent amendments in the Act.
Only 24% participants said that the recent amendments was very good, 12% said that they were necessary but still 12% doctors believed that there is a scope for further amendments in the Act.
Recommendations
The continued medical education (CME's) should be planned for the gynecologists to teach them about the legal aspects and recent amendments in the abortion laws.
Government should take efforts to increase the awareness about this laws from government publications/circulars or from media.
Government should make some new amendmets in the abortion laws taking in consideration the point of view of gynecologists.
Implications
This study will highlight the viewpoint of registered private medical gynecologists who are authorized to provide abortion services. Their opinion will help in overcoming the loop holes in proper implementation of abortion laws and sex determination in our system.
This will fill in the gap between woman, doctor and legal aspects, thus help all the three to maximize the output and also save the women from illegal and unsafe abortions.
