WWPP5533 ccoovveerr..aaii 99//22//22000088 11::3333::0066 PPMM DDHHSS WWOORRKKIINNGG PPAAPPEERRSS Determinants of Induced Abortion and Its Consequences on Women’s Reproductive Health: Findings from India’s National Family Health Surveys C M Y CM MY CY CMY K Sutapa Agrawal 2008 No. 53 DEMOGRAPHIC AND August 2008 HEALTH This document was produced for review by the United States Agency for RESEARCH International Development. The DHS Working Papers series is an unreviewed and unedited prepublication series of papers reporting on research in progress based on Demographic and Health Surveys (DHS) data. This research was carried out with support provided by the United States Agency for International Development (USAID) through the MEASURE DHS project (#GPO-C-00-03-00002-00). The views expressed are those of the authors and do not necessarily reflect the views of USAID or the United States Government. MEASURE DHS assists countries worldwide in the collection and use of data to monitor and evaluate population, health, and nutrition programs. Additional information about the MEASURE DHS project can be obtained by contacting Macro International Inc., Demographic and Health Research Division, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-572-0999; e-mail: [email protected]; internet: www.measuredhs.com). Determinants of Induced Abortion and Its Consequences on Women’s Reproductive Health: Findings from India’s National Family Health Surveys Sutapa Agrawal* Macro International Inc. August 2008 *Corresponding author: Sutapa Agrawal, Assistant Professor, International Institute of Health Management Research, Plot 3, HAF Pocket, Sector 18A Phase II, Dwarka, New Delhi –110075, Ph: 91-11-320-20115, E-mail: [email protected] or [email protected]. ACKNOWLEDGEMENTS Author is thankful to Vinod Mishra, Sarah Bradley and Praween Agrawal for their invaluable comments. Thanks are also due to the financial support by the United States Agency for International Development (USAID) for fellowship support through the MEASURE DHS project at the Macro International Inc. ABSTRACT Objectives. To study the determinants of induced abortion among women in India and to examine the consequences of induced abortion on women’s reproductive health. Methods. The analysis is based on 90,303 ever-married women of reproductive age, 15-49 years, included in India’s second National Family Health Survey, conducted in 1998-99. Covariates included in the study are sex composition of living children, sex preference, women’s age at effective marriage, urban/rural residence, religion, caste/tribe, couple’s education, couple’s working status, media exposure, wealth status, and women’s autonomy. Binary logistic regression methods were used to examine the association between induced abortion and possible determinants, as well as consequences of induced abortion on women’s reproductive health. Results. At the national level, sex composition of living children, women’s autonomy, urban residence, couple’s education, and wealth status were found to be significantly associated with experience of induced abortion among women. However, the factors associated with induced abortion are found to be different in two distinct sociocultural set-ups in India. Although sex composition of living children and couple’s education were the major factors for induced abortion in the northern group of states, wealth status and caste/tribe status were the major factors for the southern group of states. The analysis also shows that, independent of other factors, the likelihood of experiencing any reproductive health problems was 1.5 times higher (odds ratio, 1.46; 95 percent confidence interval, 1.33-1.60; P < .001) among women who had one induced abortion and 1.9 times higher (odds ratio, 1.85; 95 percent confidence interval, 1.52- 2.27; P < .001) among women who had two or more induced abortions compared with women with no history of induced abortion. Conclusions. This study identifies women’s desire to limit family size with preferred sex composition of children as an important determinant of induced abortion in India. The study also suggests that induced abortions may have negative consequences for women’s reproductive health. There is a need for more in-depth qualitative studies at the regional level to better understand the determinants and consequences of this complex and sensitive issue in India. Programs should focus more on the availability and accessibility of contraceptives among women to elude the reproductive health consequences of induced abortion. Keywords: Induced abortion, son preference, women’s autonomy, reproductive health, India INTRODUCTION Induced abortion is a complex issue that occurs at the interface of cultural attitudes, prejudices, and modern technology, and it is a sensitive issue because it directly enters into the private arena of pregnancy and reproductive rights. Worldwide, induced abortion represents an important aspect of women’s reproductive health and rights. Under the 1971 Medical Termination of Pregnancy Act, a woman in India can legally obtain an induced abortion if her pregnancy carries the risk of grave physical injury, endangers her mental health, is the result of contraceptive failure (in case of a married woman) or rape, or is likely to produce a child with physical or mental abnormalities (Ministry of Health and Family Welfare, 2003). In the global context, in which induced abortion is restricted by law and even criminalized in several countries, India enjoys the dubious distinction of being a country in which induced abortion is legal but largely unsafe and unavailable (Ravindran, 2002). Sources of data on induced abortion in India somehow fail to provide consistent estimates of induced abortions in India (Ganatra, 2000; Khan et al., 1998), but most researchers using direct and indirect methods of estimation seem to agree that there are between five and seven million induced abortions per year (Chhabra, 1996; Chhabra and Nuna, 1994; Coyaji, 2000; Faundes and Hardy, 1997; Indian Council of Medical Research, 1989; Jejeebhoy, 1999; Saha and Chatterjee, 1998). Despite the intensive national campaign for safe motherhood and legalization of induced abortion that took place in India long ago, morbidity from abortion has remained a serious problem for Indian women (Johnston, 2002). Still, there has been little public debate on this issue. Instead, discussion of induced abortion in India has mainly centered on the declining sex ratio, sex-selective abortion, and the proliferation of abortion clinics in urban areas. Not much is 1 known about the consequences of induced abortion on women’s reproductive health problems. Moreover, among the issues related to reproductive health, none has more controversial connotations than induced abortion (Mundigo and Indriso, 1999). The sociodemographic and public health importance of induced abortion in India requires a more thorough understanding of the factors associated with it. More studies on induced abortion in India concentrate on abortion rates and ratios and on the demographic profiles of women. Much less is known about the socioeconomic and gender power context underlying a woman’s undergoing an induced abortion. Identifying these and other factors that lead to induced abortion has important policy implications (Pallikadavath and Stones, 2006; Visaria and Visaria, 1995). In India, the social and cultural context within which the induced abortions are performed, the levels and characteristics of women resorting to induced abortion, and its consequences on women’s health are unknown. Without such information, it is easy for policymakers to avoid politically sensitive decisions about this important aspect of women’s health and rights. An understanding of such variation in societies would offer insight into the specific conditions that attenuate preference for sons or that perpetuate it—information that could be of use in devising policy interventions to alleviate discriminations against females. Using nationally representative data, this study examines the different factors that lead women in India to have induced abortions. The study also aims to examine the consequences of induced abortion on women’s reproductive health. 2 An extant literature review is done in the following paragraphs to develop a theoretical support and understanding of the wider dimensions of the complex and sensitive issue of induced abortion among women in India. Son Preference and Induced Abortion Studies in India have identified three major factors that underlie son preference. One is the economic utility of sons: Sons are more likely than daughters to provide family labor on the farm or in a family business, to earn wages, and to support their parents during old age, although there is some recognition that sons are no longer a dependable source of old age support (Bardhan, 1985 Basu, 1989; Dharmalingam, 1996; Miller, 1981). Upon marriage, a son brings a daughter- in-law into his family, and she provides additional help around the house as well as an economic reward in the form of dowry payments. Another important advantage of having sons is their sociocultural utility. In the context of India’s patrilineal and patriarchal system, having one son is imperative for the continuation of the family line, and many sons provide additional status to the family (Caldwell et al., 1989; Dyson and Moore, 1983). Finally, the utility of having sons arises from the important religious functions that only sons can provide. According to Hindu tradition, sons are needed to kindle the funeral pyre of their deceased parents and to help in the salvation of their souls. A cultural preference for sons (Arnold and Liu, 1986; Coombs, 1979; Coombs and Sun, 1978; Das Gupta, 1987; Gu and Li, 1994; Lavely et al., 2001; Miller, 1997; Skinner, 1997; Westley, 1995; Williamson, 1976) may be a factor driving recourse to induced abortion in India, as women carrying female fetuses may decide to terminate their pregnancies (Arnold et al., 2002; 3 Sudha and Rajan, 1999). Two recent studies in India have linked son preference to high sex ratios at birth, which indicate sex-selective abortion (Arnold et al., 2002; Retherford and Roy, 2003). Son preference is common in India, and there is evidence that this type of gender bias is increasing and spreading in modern India (Bose and Trent, 2006). The root of son preference in India lies in deeply entrenched social, cultural, and economic discrimination against women and girls. A variety of factors influence couples to have male children, such as continuation of family lineage, ritual and religious purpose, economic reasons, old age dependence, upward social mobility, and source of power (Coombs and Sun, 1978; Kapadia, 1966; Lahiri, 1984; Oldenburg, 1992). Son preference is important because where it exists, females may encounter discriminatory treatment, and female infants and children may be at a higher risk of death (Arnold et al., 1998; Choe et al., 1999; Das Gupta, 1987; Hill and Upchurch, 1995; Kishor, 1995; Koenig and D’Souza, 1986; Muhuri and Preston, 1991; Murthi et al., 1995; Pebley and Amin, 1991; Pelletier, 1998; Tabutin and Willemes, 1995). Moreover, declining fertility has meant fewer sons, and falling fertility rates may have increased son preference in India (Basu, 1999, 2000; Bhat and Zavier, 2003; Das Gupta, 1987; Das Gupta and Bhat, 1997). However, at the same time, modernizing factors including education, urbanization, and exposure to mass media also help in reducing preference for sons (Bhat and Zavier, 2003). Abortion of fetuses because they are female is a profound and increasing problem throughout South Asia, including India. The advent of sex-selection technologies in India has added a new dimension to the discriminatory practices against girls. Strong son preference and associated sex-selective abortion are also believed to be partly responsible for a rising child sex 4