A Study on Knowledge and Attitude on Comprehensive Abortion Care (CAC) among Married Women of Reproductive Age Group with a View to Develop an Awareness Program in a Selected Rural Community, West Bengal

Introduction:

Government of India (GOI) launched the Reproductive and Child Health Program (RCH) since October 1997. Among the different strategies of reproductive health, safe/legalized abortion in India has remained neglected so far.^[1] Unsafe/illegal abortion is a significant but preventable cause of maternal mortality.^[2] Lack of available, accessible, effective, safe abortion services by qualified persons in hygienic condition and absence of knowledge regarding the same in the community is one of the important reasons even after more than 45 years of enactment of MTP 1971 act In India.^[3] Fortunately, this aspect is being reviewed now.

Comprehensive Abortion Care (CAC),^[4] under the Ministry of Health & Family Welfare, National Health Mission (NHM) is a term "rooted in the belief that women must be able to access high-quality, affordable abortion care in the communities where they live and work", was first introduced in India by Ipas in 2000.^[5] After successful pilot studies in three states, transformation of abortion services from only clinical procedures to a comprehensive women-centred service from conception up to post abortion care including pain management were gained impetus. One of the important successes of those efforts was changing the terminology from MTP to CAC, thus accepting the centrality of the woman.^[5] Comprehensive Abortion Care includes all of the elements of post abortion care (PAC)[Treatment, Counselling, Contraceptive & Family Planning, Reproductive & other health services] as well as safe abortion care (SAC).^[6] In 2015-19, there were on average 1210 million unintended pregnancies each year globally, equal to a global annual rate of 64 unintended pregnancies/1000 women aged 15-49 years means 48% were unintended. In the same time, there were 73•3 million abortions annually, corresponding to a global annual rate of 39 abortions / 1000 women aged 15-49 years means that 61% of unintended pregnancies had abortion.^[7]

As per WHO Lancet study, out of the total 48.1 million pregnancies in India, estimated unintended pregnancy rate was 70/ 1,000 women aged between 15-49 in 2015.^[8]

A study conducted by the International Institute for Population Science (IIPS), Mumbai, the Population Council, New Delhi and the Guttmacher Institute based in New York found that an estimated 15.6 million abortions occurred in 2015 in India and the abortion rate was 47/1000 women aged 15-49 years. About 81% used medication abortion method (MMA), 14% carried out surgical abortion method, and the rest 5% abortions were carried out outside the health facilities using other (probably unsafe) methods. Around 22% of abortions in India took place in health facilities, 73% used drugs from chemists and informal vendors, outside the health facilities (MMA) and 5% did outside of health facilities using methods other than medication abortion.^[9]

With this background a study was conducted with the objective of assessing the knowledge and attitude regarding CAC among married women of reproductive age group in selected rural community, West Bengal India.

Materials and Methods:

A descriptive type of observational study, cross sectional in design was conducted among married women of reproductive age group in selected villages of Gazole and Bamongla Block of Malda District, West Bengal, India from 9/2017 to 9/2018, over a period of 1 year. Inclusion criteria were 15-45 years married women, permanent resident of the village, present during the data collection period and gave informed written consent to participate in the study Seriously ill women were excluded from the study. Study tool was a pre designed pre tested structured schedule, Likert scale, structured opinionnaire. The schedule had four parts­Part I Consisted of information on the socio-demographic profile; Part II consisted of questions on knowledge about comprehensive abortion care; Part III dealt with questions regarding attitude about comprehensive abortion care and Part IV was Opinionnaire for evaluation of the awareness program The schedule was designed in consultation with three experts; 2 from nursing field and 1 from gynaecology & obstetric depart-ment, it was pretested on 20 married women of reproductive age group of the same blocks; then modified, necessary changes were done and validated by another 3 experts. Study technique was face-to-face interview and all questions were asked in local languages.

Results:

Socio-demographic profile of the study population were demonstrated in Table 1. Out of total 400 study population who were interviewed, majority (61.5%) belonged to the age group of 25-35 years with mean age of 30.7± 8.3 years and about 78.5% followed Hinduism. Regarding education, about 35% completed Secondary education whereas 18.5% were illiterate. About 59.5% came from nuclear family, 75.5% were home makers, 41% were married for 1 to 5 years, 43% had one child, and 64% not opted for abortion. About 41% of the study population had monthly family income of Rs. 10000- 15000.

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Data presented in Table 2 revealed that the knowledge score of married women of reproductive age group ranged between 3-18 with a mean score of 11.52, median 11, standard deviation 2.79, and Interquartile range was 4. Similarly the attitude score ranged between 24-120 with a mean score of 84.45, median 84, standard deviation 8.31, and Interquartile range was^[10].

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Indicators of knowledge of the study population were showed in Table 3. About 55.5% knew correctly the meaning of abortion, 78.5% told correctly the place for termination of pregnanc, 76.5% knew the best method to prevent unwanted pregnancy, and 87.5% told correctly why Comprehensive Abortion Care is important. Factor that leads a woman to undergo abortion was known by 88.5%, cause of illegal abortion in our country was told by 82%, and best method to maintain spacing between two child births was known by 83%. Family members opinion is not mandatory for abortion procedure was known by 64.5%, and lack of awareness is the main barrier for CAC service was told by 67% of the study population. The less known part of information consisted mainly of maximum period for undergoing safe abortion for a woman (26.5%), follow-up after abortion (37%), who are the beneficiaries for CAC(50%),when a woman should start using contraception after abortion(53%) and which is not a reproductive right (47%).

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Data presented in component bar diagram revealed that 264(66%) of the study population had adequate knowledge whereas 312(78%) woman of reproductive age group had positive attitude regarding CAC (Figure 1).

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Figure 1:

Distribution of the study population according to Knowledge and Attitude regarding Comprehensive Abortion Care (N=400)

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Correlation co-efficient and their significance between knowledge score of the Woman of reproductive age group and their attitude towards CAC described that 'r' value computed between knowledge and attitude score was 0.074, indicating very weak correlation between the two variables. The calculated 't' value between knowledge and attitude was 1.04, which is not statistically significant at 0.05 level of significance (Figure 2).

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Figure 2:

Scatter plot of knowledge versus attitude

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Acceptability of the awareness program-Almost all of the study population (99%) were strongly agreed that the awareness program regarding CAC were helpful for learning, it also provided necessary information about Comprehensive abortion care.

Discussion:

Unsafe/illegal abortions account for 8% of all maternal deaths in India. The barriers which impede women from reaching the required safe abortion services include illiteracy especially female illiteracy, lack of awareness, lack of access to health facilities, distance, lack of confidentiality, anonymity, privacy and respect towards women.

This study has tried to assess knowledge and attitude on Comprehensive Abortion Care (CAC) among married women of reproductive age group in selected rural community of West Bengal, India.

The present study finding indicates that majority (61.5%) of the study population belonged to the age group of 25-35 years with mean age was 30.7±8.3 years which was more than a study conducted by Adera et al at Ethiopia 9 among Women of Reproductive age group (37.8%), Bamnia et al at Mewar, Rajasthan 10 (56%), Cresswell et al at Zambia (33%) 11, Banerjee et al at Bihar and Jharkhand (56%)12, Srivastava et al at Indore(53.33%)13 and Khanal et al at Nepal(47%).14In the present study 40.5% participants belonged to joint family whereas it was 56% at Bihar and Jharkhand.12 In our study 19% were illiterate which was almost similar to Ethiopia (16%)8, but lower than Rajasthan (40%)10 & Indore (40.5%) 13 and higher than Zambia(4%). 11 About 43% women had one child in this study, which was nearly similar to Rajasthan (33%)10 and Indore (33.8%). 13 This study revealed that 64% had no abortion history, whereas in Bihar and Jharkhand 85.7% had no spontaneous abortion and 95.4% had no induced abortion. 12 About 14% of women reported at least one spontaneous abortion, while induced abortions were reported by only 5% of women in Bihar and Jharkhand12, which was much less than our study (26%).

Regarding knowledge, 76% knew correctly about conditions in which a pregnant mother can have a legal abortion service in Ethiopia 9 which was in line with this study (71%). On the contrary, just 16% of women of reproductive age correctly identified the grounds for which abortion is legal in Zambia.11 Only 40% of women of reproductive age group knew that the extreme situation where the pregnancy threatens the life of the mother was grounds for a legal abortion. About 55% of study population answered the definition of abortion correctly in the present study while 38% defined correctly in Ethiopia 9 and 23.8% in Nepal.14 Among the sampled population only 26.5% knew about the time for eligible termination of pregnancy, in contrast to 77% of Ethiopia 9 and 70% in Nepal.^[14] About 78.5% of the respondents knew safe abortions are performed at government approved institutions which was similar to Nepal (68.9%)14 but higher than Mewar (58%)10 and Bihar (46%).12 About 27% of participants were aware about the usage of contraceptives in Mewar 10 in contrast to 53% in the present study. The main reason for undergoing abortion was failed contraception followed by unplanned pregnancies in Mewar 10 and Indore (38.1% and 32.38%) ^[13] in contrast to this study where it was unplanned pregnancy (88%). We found that gestation limits for legal MTP was known by 26.5% which was much higher than Bihar 12 where it was only 1.9%. Though the MTP Act has existed for almost five decades in India, more than half of the women in this study and Bihar study were unaware that abortion is legal in India, and very few of them were aware of particular aspects of the law.12On the whole, the level of satisfactory knowledge of abortion among the women interviewed was 66% and in Nepal it was 53.5%.^[14]

Women's attitudes towards abortion were not very conservative unlike Zambia study.11Only 22% of the participants of this study had not positive attitude towards abortion, similar to Ethiopia study (23%).9In Zambia 11 majority of the women (90%) had poor attitude regarding Comprehensive Abortion Care. More than 90% of women either agreed or strongly agreed with the statement 'abortion is immoral' in Zambia study^[11], in line with our study (82%). Conversely, the majority of women either disagreed or strongly disagreed with the statements 'women should have access to safe abortion services' (86%); like Zambia study (81%) 11and 'unmarried women should have access to safe abortion services' (79%).

Conclusion:

Our findings showed satisfactory knowledge and positive attitude of the married women of reproductive age group regarding Comprehensive Abortion Care were 66% and 78% respectively. We need to impart awareness programme on Comprehensive Abortion Care. The concept of CAC was well accepted to the married women of reproductive age group and they are interested to learn more regarding CAC. However, changing community knowledge and attitudes is challenging, especially when the topic is stigmatised. Additional interventions are needed like spreading of awareness through mass media and interpersonal communication.