|Year : 2019 | Volume
| Issue : 1 | Page : 42-47
Pro-life or pro-abortion – Women's attitude toward abortion in Darjeeling, India
Pallabi Dasgupta1, Romy Biswas2, Dilip Kumar Das3, Jayanta Kumar Roy2
1 Institute of Public Health, Kalyani, Nadia, West Bengal, India
2 Department of Community Medicine, North Bengal Medical College and Hospital, Siliguri, West Bengal, India
3 Department of Community Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
|Date of Web Publication||12-Jun-2019|
Dr. Pallabi Dasgupta
Institute of Public Health, Kalyani, Nadia, West Bengal
Source of Support: None, Conflict of Interest: None
Background and Objective: Despite liberal abortion law in India, majority of abortions are unsafe. Behavioral theory suggests that women's attitudes may influence their abortion decisions. The present study was conducted to find out women's attitude toward abortion and its predictors. Materials and Methods: A community-based cross-sectional study was conducted in Naxalbari block of Darjeeling district, West Bengal, India, among 420 women aged 15–49 years using a predesigned, pretested interview schedule. The women's attitude regarding abortion practices was determined based on Likert's three-point scale. Two-stage cluster analysis was used to classify the overall attitude of women. Binary logistic regression was used for finding out predictors of abortion attitude. Results: More than half (53.5%) of the women had an overall pro-life attitude and 46.5% women had an overall pro-abortion attitude. Women who were less educated with <5 years' schooling, unaware of legality of abortion, and never aborted had significantly higher odds of having overall pro-life attitude. Majority women viewed abortion as a sin (81.4%); 62.1% of women disagreed with abortion as a method of family planning; 87.4% disagreed with sex selection before abortion; and 57.4% women agreed on women's right to decide for abortion. Conclusion: Women's attitude of abortion depicted complex personal and moral choices marred with social stigma within which abortion decisions are made. For developing a pro-choice outlook, life skills education for women, creating supportive family environment, sensitizing young men through extensive awareness campaigns, and advocacy through health-care providers are needed.
Keywords: Abortion, attitude, India, women
|How to cite this article:|
Dasgupta P, Biswas R, Das DK, Roy JK. Pro-life or pro-abortion – Women's attitude toward abortion in Darjeeling, India. Arch Med Health Sci 2019;7:42-7
|How to cite this URL:|
Dasgupta P, Biswas R, Das DK, Roy JK. Pro-life or pro-abortion – Women's attitude toward abortion in Darjeeling, India. Arch Med Health Sci [serial online] 2019 [cited 2019 Dec 13];7:42-7. Available from: http://www.amhsjournal.org/text.asp?2019/7/1/42/259999
| Introduction|| |
Pregnancy is a natural phenomenon. In view of this, the need for abortion will always remain irrespective of the reason. Abortion, being a sensitive issue, is possibly the most neglected and underexplored women's health issue leading to maternal morbidity and mortality. Nearly 97% of unsafe abortions take place in developing countries. About 8% of maternal deaths in India are attributed to unsafe abortions.
The viewpoint of different persons has been different on the matter of abortion. Some argue on its ethicality and others opine that it is a right of a woman to choose whether she wants to give birth or not. Over the past 15 years, abortion has been increasingly viewed in perspectives of human rights such as right to life, health, equality, nondiscrimination, liberty, and security of privacy. In 1999, the UN Committee on the Elimination of All Forms of Discrimination against Women supported decriminalization of abortion. Despite difference in ideologies, between 1995 and 2005, about 12 countries legalized abortion, including neighbor Nepal though under varied restrictive circumstances.
India legalized abortion as early as in 1971 by the Medical Termination of Pregnancy (MTP) Act. Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994 was passed to curb sex-selective abortions. The Government of India policies under Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH + A) gave considerable focus toward comprehensive abortion care.
Despite these efforts, a clear majority of abortions are believed to be performed outside registered centers in India. A wide range of physical, economic, social, and policy factors limit the access to competent care. Social factors such as stigma, conscientious objection to abortion in community, gender discrimination and low status of women, women avoiding male providers, lack of understanding and awareness of rights, and provider's attitude result in women conforming to unsafe methods.
Behavioral theory suggests that women's attitudes, perceived norms, and knowledge of abortion may prevent them from considering it as an option. Pregnancy termination may be against women's personal, moral, and religious beliefs. While understudied, it is possible that abortion attitudes of women affect abortion-seeking decisions, behaviors, and experiences. For instance, research has shown that a woman's abortion attitudes are even related to the type of procedure that she elects. The pro-life (emphasizing the right of the embryo or fetus to gestate and be born) and pro-abortion (emphasizing the right of women to choose whether to abort a pregnancy or to preserve it) abortion debate might influence the moral status of abortion. Issues of women's attitude have been dealt with in studies addressing the Indian context in Gujarat, Bihar, Jharkhand, and Uttar Pradesh.
It is necessary to understand women's viewpoint regarding abortion for implementing the strategies to diverse population groups in a better way by the public health managers. Locally, Darjeeling district has higher abortion percentage (8.1%) than the state percentage (West Bengal [WB], 4.4%). In this context, the present community-based study was conducted with the objective of finding out women's attitude toward abortion and its predictors in a block of Darjeeling district, WB.
| Materials and Methods|| |
Study design, study area, and subjects
A community-based cross-sectional study was conducted from May 2017 to April 2018 in Naxalbari block of Darjeeling district, in the state of WB, India. The district is bounded on the north by Sikkim, on the south by Kishanganj district of Bihar state, on the east by Jalpaiguri district, and on the west by the country of Nepal. The Naxalbari block consists a total of 170 villages covering a population of 165,523 as per census 2011. It has structured government health-care delivery system with North Bengal Medical College serving as the tertiary referral institution. The study participants were women in the reproductive age group of 15–49 years who were resident of the study area for at least 1 year.
| Sampling|| |
Sample size was estimated using single proportion formula for cross-sectional studies. This study is a part of unpublished work on abortion, where proportion of abortion event in lifetime of women in reproductive age group was main outcome variable. Hence, considering 95% level of confidence, 15% of relative precision, design effect of 2, and anticipated proportion of abortion event as 45.7%, final sample was 420 women.
Cluster sampling was applied to select the participants. Thirty clusters (villages in Naxalbari block) were identified by probability proportional to size. An equal number of women were included from each cluster; thus, cluster size was 14. In an identified cluster, sampling frame of women aged 15–49 years was prepared beforehand with the help of local authorities. From each cluster, 14 women were selected by simple random sampling (without replacement). Unwilling women, seriously ill, those withdrawing from study, or women unavailable even after three visits were considered nonresponders. Nonresponders among the selected 14 women per cluster were replaced from the same sampling frame from the same cluster.
Tools and techniques: Data collection
Data were collected by interviewing the women and reviewing relevant medical records/prescriptions. A predesigned interview schedule consisting of background characteristics, history of any abortion, awareness regarding MTP Act and attitude regarding abortion, abortion practices, and services was prepared. Before starting the present study, the schedule was validated in local vernacular by initial translation, back-translation, and re-translation, followed by pretesting among a convenient sample of 30 women in the reproductive age group residing in a village of another block in the district.
Background characteristics included age (in completed years), religion, education (<5 years or ≥5 years' schooling), type of family (nuclear or joint), marital status (unmarried or ever married), and socioeconomic status (SES) using a modified BG Prasad scale based on the All India Consumer Price Index of June 2017.
The women's attitude regarding abortion practices was determined based on Likert's three-point scale by composing statements relating to prevention, cause, and care seeking for abortion. Three responses were assessed for each category “agree (A), neutral (N), or disagree (D).” Points 1–3 were assigned to the responses depending on the statement. The person who “agreed” with a “positive statement” got the maximum points. The scoring for positive statements was D = 1, N = 2, and A = 3. Likewise, the scoring for negative statements was D = 3, N = 2, and A = 1.
After necessary approval from authorities, data were collected at the households of selected participants with prior informed consent maintaining privacy, confidentiality, and anonymity.
A two-stage cluster analysis was performed among the sample to identify groups of women who were homogeneous within themselves but heterogeneous with each other, regarding their attitude toward abortion. Before the cluster analysis, the presence of outliers, collinearity among variables, and the adequacy of sample size were examined. Using log-likelihood distance measure, noise handling (taking default 25%) for outliers, a two-cluster solution was retained. Individual attitude questions as well as the total score of responses in Likert's scale were used in the cluster analysis. Cluster of women with higher mean scores was labeled as “pro-abortion attitude” and other as “pro-life attitude.” For this study, “pro-abortion” was conceptually defined as those having supportive attitude toward abortion and abortion services and “pro-life” as unsupportive attitude.
Predictors of overall attitude toward abortion among participants were analyzed using binary logistic regression. In this analysis, age, religion, type of family, education, SES, marital status, knowledge of legality of abortion, and abortion status were the categorical predictor variables. “Pro-abortion attitude” and “pro-life attitude” were used as the dependent variables, dichotomous in nature, where pro-life attitude = 1 and pro-abortion attitude = 0. The difference in attitude between the ever-aborted and never-aborted women was assessed using Mann–Whitney U-test considering individual statements. P < 0.05 was considered as statistically significant. The analysis was done by IBM SPSS version 20 (IBM Corp., Armonk, NY, USA).
| Results|| |
A total of 420 women aged 15–49 years were interviewed from 30 selected villages in Naxalbari block. The mean age of participants was 26.4 ± 7.1 years (range, 15–49 years), and majority belonged to the age group of 21–30 years (56.7%). Majority were ever married (318, 75.7%), Hindu (367, 87.4%), belonging to joint family (221, 52.6%), educated with at least ≥5 years' schooling (312, 74.3%), and belonging to SES Class III (150, 35.7%) and Class II (130, 31. 0%). About 141 (33.6%) of women gave a history of any abortion in their lifetime and 279 (66.4%) never aborted. Only 122 (29.0%) women were aware of legal status of abortion in India.
Attitude regarding abortion
Majority of women disagreed that abortion is a method of family planning (62.1%); abortion should be done by a doctor at any place (66.4%) and that mother is always responsible for abortion (75.0%). Most of the women (87.4%) disagreed with sex selection before abortion. About 81.4% of the women agreed that abortion is a sin and abortion should not be provided for any reason (49.3%), but fetus having multiple abnormalities should be aborted (49. 5%). Majority agreed that women should have the right to decide for herself whether to have abortion (57.4%) and abortion should be done by some trained health personnel (74.5%) [Table 1].
Regarding association between the abortion status of women and their attitudes, significantly higher proportion of women who have never aborted believed that abortion is a sin (84.6% vs. 75.2%) and mother is always responsible for abortion (19.4% vs. 8.5%). However, significantly higher proportion of women who have ever aborted believed that sex selection in utero, followed by abortion, should be done (7.8% vs. 3.6%) [Table 2].
|Table 2: Attitude regarding abortion according to abortion status of the women (n=420)|
Click here to view
Cluster analysis among participants regarding their responses to attitude statements revealed more than half (213, 53.5%) of the women had an overall pro-life attitude and 185 (46.5%) women had an overall pro-abortion attitude. Another 22 could not be classified to any of the clusters, i.e., outliers. Most important predictors for the clusters were the total score, followed by statements “fetus having multiple abnormalities should be aborted” and “abortion should not be provided for any reason” [Table 3].
|Table 3: Predictors of overall attitude toward abortion among participants (n=398)**|
Click here to view
Predictors of overall attitude toward abortion among participants
Women who were less educated with <5 years' schooling (adjusted odds ratio [AOR], 1.761; 95% confidence interval [CI], 1.058–2.931), unaware of legality of abortion (AOR, 2.215; 95% CI, 1.396–3.516), and never aborted (AOR, 1.960; 95% CI, 1.241–3.095) had significantly higher odds of having overall pro-life attitude. Those belonging to lower socioeconomic status Classes III, IV, and V, Muslim/Christian religion, and joint family had higher likelihood of having overall pro-life attitude toward abortion [Table 3].
| Discussion|| |
Abortion leads to various legal, moral, and ethical dilemmas. Women's abortion choices are usually influenced by these ideologies. In India, under the MTP Act, abortion is a qualified right where women can go for abortion due to certain clauses. In this backdrop, the present study explored the attitude of women in this regard.
Abortion and moral implications
Controversies exist in whether life begins in the womb or not. One view is that fetal life does not start at conception; life starts during the 5th month of gestation. Different religious views also influence abortion and the various actions pertaining to it. The teachings of prominent religions are consistent with a pro-life view. Women perceived abortion, an act of guilt of taking away life in Puducherry. Even, health-care providers have moral-, social-, and gender-based reservations about induced abortion. These reservations might influence attitudes toward abortions. In general, conscientious objection toward abortion is prevalent in the Indian context.
Abortion and rights of women
When it comes to abortion decision-making, woman tends to consult with her husband, mother, mother-in-law, family relatives, friends, and the abortion-care providers. Unlike the present study findings, women in Gujarat and Jharkhand believed that only men can decide whether a woman should have an abortion. However, various reproductive health advocates and medical personnel have been encouraging and emphasizing the allowance of women to use their reproductive health rights in making their own informed decision.,
Abortion and sex selection
Indian law does not support sex selection as a clause for abortion. Interviews with ever-aborted women suggested a strong preference for a male child in few case studies in WB. Given the improved sex ratio in WB as per the fourth National Family Health Survey (NFHS-4), it seems that a balanced family, with both sons and daughters in the family, was more preferred among the respondents rather than having a strong unidirectional preference for a male child. Similar observations were found by other authors., Kansal et al. found that majority (66.0%) of the women did not prefer any gender, followed by male preference (22.2%) and female preference (11.8%). Only 13% of the women in Madhya Pradesh support an abortion because the fetus is a girl.
Abortion as contraception
Previous studies found many women considering abortion as a method of contraception due to the lack of proper knowledge and motivation for the use of contraception contrast to the present findings. The main reason for abortions here was completed family size. Women considered sterilization better than undergoing repeated abortions in Puducherry.
Overall attitude toward abortion
Overall support for abortion is varied within India. A large-scale study in Madhya Pradesh reported that only 7% of women approve of abortion and 23% gave circumstantial approval. Banerjee et al. reported women having poor individual attitudes and poorly perceived community acceptability of abortion in rural districts in Bihar and Jharkhand. Exposure to an abortion message was found to be positively associated with attitude and higher perceived availability of the services. Pro-abortion attitudes toward abortion were associated with characteristics such as higher levels of education, awareness of the legal status of abortion, source of abortion services, an abortion method, and exposure to an abortion. Predictors of negative attitudes toward abortion were women in the medium and high living standard groups compared to the poorest women in contrast to the present findings.
Evidence differs whether education level increases or decreases chances of opting abortion. Facility-based studies show women of lower education level seeking abortion in India., Population-based studies, found women of higher educational status reporting higher abortion figures as in the present finding. This may be probably due to their awareness regarding implications of larger family size and awareness of legality of abortion.
Knowledge of legality of abortion among Indian women is generally poor as reported from various studies. These might lead to misconceptions regarding various aspects of abortions, evolving a pro-life attitude. Although unplanned pregnancy and abortion is a stressful situation, those who have aborted might have better awareness regarding the aspects of abortion, developing a pro-abortion attitude.
All the prominent religions in India advocate pro-life view. Muslim religious beliefs often prelude the use of abortion. Regular church attendance was associated with pro-life attitude in other studies. Since the overall proportion of women belonging to Hindu religion were more, the findings, however, cannot be generalized here.
In Bihar and Jharkhand, many women perceived that they have strong family social support systems for abortion when required. Women residing in joint families were more likely to have pro-life view in the present study. Probably, they are influenced by family, social norms, and customs. The economic support of rearing another child in case of unintended pregnancy is also more likely in joint families. Going for abortion in case of a woman belonging to nuclear family is much easier due to less chance of being known by others. A study analyzing secondary data of the NFHS-2 of rural India had shown that women's autonomy influences many reproductive health outcomes.
The present study tried to elicit attitude regarding few of the aspects of abortion among the women. A qualitative exploration would have added to better understanding of the area. The area of research being a sensitive issue, the respondents might have been hesitant to answer all the questions properly. However, household setting of the study and adequate privacy during interviewing have tried to reduce the possibility of social desirability bias.
| Conclusion|| |
Absolute justification for abortion which is extreme form of social approval is probably not possible in the current times. Women's attitude of abortion depicted complex personal and moral choices marred with social stigma within which abortion decisions are made. For developing a pro-choice outlook, life skills education for women, identifying safe spaces in which they can build social networks, and find social support among peers and question community stereotypes are needed. Creating a supportive family environment, sensitizing young men through extensive awareness campaigns and advocacy through health-care providers can create a supportive attitude toward abortion when needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al.
Unsafe abortion: The preventable pandemic. Lancet 2006;368:1908-19.
Maternal Health Division, Ministry of Health and Family Welfare. Comprehensive Abortion Care: Provider's Manual. New Delhi: Government of India; 2014.
Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A, et al.
Induced abortion: Incidence and trends worldwide from 1995 to 2008. Lancet 2012;379:625-32.
Government of India. The Medical Termination of Pregnancy ACT, 1971 (Act No. 34 of 1971), 10th
August 1971. New Delhi: Ministry of Health and Family Welfare; 1971.
Ministry of Health & Family Welfare. A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India- for Healthy Mother and Child. New Delhi: Government of India; 2013.
Maternal Health Division, Ministry of Health and Family Welfare. Comprehensive Abortion Care: Trainer's Manual. New Delhi: Government of India; 2014.
Montano DE, Kasprzyk D. Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. In: Health Behavior and Health Education: Theory, Research and Practice. 4th
ed. San Francisco: Jossey Bass; 2008. p. 76-96.
Kerns J, Vanjani R, Freedman L, Meckstroth K, Drey EA, Steinauer J, et al.
Women's decision making regarding choice of second trimester termination method for pregnancy complications. Int J Gynaecol Obstet 2012;116:244-8.
Holstein JA, Gubrium JF, editors. Handbook of Constructionist Research. New York: Guilford; 2008.
Gupta S, Dave V, Sochaliya K, Yadav S. A study on socio-demographic andobstetric profile of MTP seekers at Guru Govind Singh Hospital, Jamnagar. Healthline 2012;3:50-4.
Banerjee SK, Andersen KL, Buchanan RM, Warvadekar J. Woman-centered research on access to safe abortion services and implications for behavioral change communication interventions: A cross-sectional study of women in Bihar and Jharkhand, India. BMC Public Health 2012;12:175.
Boler T, Marston C, Corby N, Gardiner E. Medical Abortion in India: A Model for the Rest of the World? London: Marie Stopes International; 2009.
Kansal R, Maroof KA, Bansal R, Parashar P. A hospital-based study on knowledge, attitude and practice of pregnant women on gender preference, prenatal sex determination and female feticide. Indian J Public Health 2010;54:209-12.
] [Full text]
Ministry of Health and Family Welfare: District Level Household and Facility Survey -4; West Bengal Factsheet (2012-2013). Mumbai (India): International Institute for Population Science; 2012-2013. Available from: http://www.rchiips.org
. [Last accessed on 2018 Oct 10].
Government of India, Ministry of Home Affairs. Office of Register General and Census Commissioner. C.D. Block Wise Primary Census Abstract Data (PCA)-West Bengal. India: Government of India, Ministry of Home Affairs. Office of Register General and Census Commissioner. Available from: http://www.censusindia.gov.in/pca/cdb_pca_census/Houselisting-housing-WB.html
. [Last accessed on 2018 Oct 10].
Nojomi M, Akbarian A, Ashory-Moghadam S. Burden of abortion: Induced and spontaneous. Arch Iran Med 2006;9:39-45.
Sharma R. Revision of Prasad's social classification and provision of an online tool for real-time updating. South Asian J Cancer 2013;2:157.
Kurjak A, Carrera JM, McCullough LB, Chervenak FA. Scientific and religious controversies about the beginning of human life: The relevance of the ethical concept of the fetus as a patient. J Perinat Med 2007;35:376-83.
Duggal R, Barge S. Abortion Services in India Report of a Multi Centric Enquiry. Mumbai: CEHAT; 2004.
Navis FS, Krishnamoorthy N, Dongre A. Why women seek abortion? a qualitative study on perspectives of rural women on abortion and contraception. Int J Reprod Contracept Obstet Gynecol 2015;4:1153-7.
Rehnström Loi U, Gemzell-Danielsson K, Faxelid E, Klingberg-Allvin M. Health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: A systematic literature review of qualitative and quantitative data. BMC Public Health 2015;15:139.
Collumbien M, Mishra M, Blackmore C. Youth friendly services in two rural districts of West Bengal and Jharkhand, India: Definite progress, a long way to go. Reprod Health Matters 2011;19:174-83.
Dhar A. Abortion: A study based on case-studies of South 24-Parganas, West Bengal. Am Int J Res Humanit Arts Soc Sci 2015;10:86-9.
Ministry of Health and Family Welfare, Government of India. National Family Health Survey 2015-16: State Fact Sheet West Bengal. Mumbai (India): International Institute for Population Science; 2016.
Puri S, Bhatia V, Swami HM. Gender preference and awareness regarding sex determination among married women in slums of Chandigarh. Indian J Community Med 2007;32:60-2. [Full text]
Malhotra A, Nyblade L, Parasuraman S, MacQuarrie K, Kashyap N, Walia S. Realizing Reproductive Choice and Rights: Abortion and Contraception in India: Report. Washington DC: International Council for Research on Women; 2003.
Shrivastava N, Yadav S. The study of KAP of medical abortion in a tertiary centre. IOSR J Dent Med Sci 2015;14:1-4.
Pallikadavath S, Stones RW. Maternal and social factors associated with abortion in India: A population-based study. Int Fam Plan Perspect 2006;32:120-5.
Sebastian MP, Khan ME, Sebastian D. Unintended Pregnancy and abortion in India: Country Profile Report; March, 2014.
Misra R. Effect of age, gender and race on abortion attitude. Int J Soc Soc Policy 1998;18:94-118.
Mistry R, Galal O, Lu M. Women's autonomy and pregnancy care in rural India: A contextual analysis. Soc Sci Med 2009;69:926-33.
[Table 1], [Table 2], [Table 3]