Family matters

ANJALI RADKAR

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INDUCED abortion is a sensitive issue in the reproductive life of women. Despite its legal status for over 30 years, many women still go in for clandestine and unsafe abortions. In general both the woman and her family prefer to remain silent about the matter. This is a major hindrance in getting authentic information on abortions – as regards its estimates, whether safe or unsafe, and understanding issues surrounding it. Though abortions among married women are now gaining greater acceptance, especially in urban areas, its incidence among ‘not married’ women is neither accepted nor openly talked about.

Despite large sample surveys, collecting data on fertility of ever-married women, including on abortions, since abortion seems to be grossly underreported, the estimates are unreliable. Additional data is drawn from clinic-based studies, but this too is incomplete because such samples are selective and little information is available about the processes and patterns of abortion.

There is thus need for a study devoted exclusively to abortion. This paper is based on a qualitative study on abortion conducted under the Abortion Assessment Project (AAP-I) to understand the mechanisms of abortion and their inter-linkages – decision-making, rationale, attitudes, perceptions, reasons, quality of care, cost and feelings after abortion. This study was conducted in two purposively selected villages on the fringe of Pune city. People residing in the urban fringe experience rural living conditions and apart from being involved in agriculture related work, engage in urban occupations. Because of improved transportation facilities, commuting to nearby urban centres is easier as is the access to urban infrastructure. Thus, access to abortion serices provided in various public and private health centres in the city is easier as compared to their rural counterparts in remote, interior parts of the country.

The focus of the study is on abortions of married women in the selected villages. Initially, all currently married women in the reproductive age group were interviewed to identify the ones who had abortions. After that, in-depth interviews of these women were conducted to understand the why, where and how of their abortion. Similarly, focus group discussions (FGDs) with men and women, village functionaries and abortion providers were carried out to get an overall picture.

Out of the 940 households in both villages, 933 currently married women in the reproductive ages were interviewed for this study. Among these, 65 women reported 70 abortions. Four women had repeat abortions, three women twice and one thrice.

 

 

The profile of abortion seekers is shown in Table 1 and Table 2. Most of the abortions involved women between the ages 20 and 30. This appears consistent, as fertility in this age group is the highest. Similarly, an analysis of the reasons for abortion shows that most of them were for spacing between children and for limiting family size. Possibly, given the proximity to the city, many abortion seekers were educated. Of the 65 women only 28 were housewives while 37 women worked and earned money. Similarly, of the 70 abortions, 59 were conducted at pregnancy order three or more, indicating that the woman was ‘settled’ in the family. All these factors help ascertain the ‘say’ of the woman in family matters.

 

TABLE 1

Background characteristics of abortion seekers

Background characteristics

Number

Educational level

Illiterate

13

1-4 standard

13

5-9 standard

20

S.S.C.

11

Above S.S.C.

8

Occupation

Agriculture

25

Agricultural labour

2

Shop

4

Gardening

1

Self-employed

2

Tailoring

3

Housewife

28

Total

65

 

TABLE 2

Age and order of pregnancy at the time of abortion

Age and order of pregnancy

Number

Age at abortion

19-20

12

21-24

34

25-29

19

30 and more

5

Order of pregnancy

1

2

2

9

3

29

4

20

5

6

6

3

7

1

Total

70

 

The study is structured around three stages of the abortion process – pre-abortion, actual abortion experience and post-abortion. This paper presents information regarding the role of the family at all stages in the process of abortion. Though only the woman undergoes physical suffering in the abortion procedure, she is not alone in the process. Along with her, close family members are involved at different stages of decision-making, selecting the provider and providing moral support by accompanying her to the hospital and/or sharing household responsibilities. Thus, though abortion is a very personal decision of the couple, the family and people around have a role.

 

 

Information on the secrecy related to pregnancy provides an idea whether women felt guilty or were embarrassed to let others know about the pregnancy. Since the respondents in this study are currently married women, the issue of secrecy takes a milder form as compared to abortions of unmarried women.

However, our study shows that in 13 cases secrecy about the pregnancy was maintained from outsiders, though all family members knew. When the reasons for abortion in these 13 cases were studied, it emerged that in all 8 cases of abortion of female foetus, no secrecy was maintained. By the time the test was conducted, the pregnancy was already advanced (up to 4-5 months). Further, none of these women had a son before. This is probably why everyone knew about it. In cases where the pregnancy was kept secret, the reasons for abortion include family size complete (5), spacing between the children (2), problem to child or mother (4), husband wanted to remarry (1) and pregnancy immediately after the marriage (1).

 

 

Only in one case was the husband kept in the dark about the pregnancy. This was because the woman earlier had two mentally challenged children. Her husband wanted one more child – a son – and felt that they could get a normal child as one of their daughters was absolutely normal. In all other 69 cases the husband was aware of the pregnancy. The first person to be consulted about an unwanted pregnancy is often the husband (Sinha et al. 1998). In 50 cases the mother-in-law knew about the pregnancy whereas the parents of the woman were informed about it in only 16 cases.

With whom do women discuss the pregnancy and who advises them to undergo abortion? Are women themselves involved in the decision-making process? According to Ganatra (2000) decision-making is one of the least studied areas of abortion behaviour. This paper attempts to shed some light on the dynamic process of decision-making related to abortion.

 

 

In the event of an unwanted pregnancy, the husband is normally the first person to be consulted; then the mother-in-law or other female relatives. But in most cases abortion is a joint decision of husband and wife (Khan et al. 1990, Sinha et al. 1998, Ganatra 2000). This study reports that the woman herself was involved in decision-making in 51 cases and the husband in 57 cases. In 49 out of 70 abortions, it was a joint decision by the couple. In four cases the mother-in-law was actually involved. Thus the role of the husband is more important than the occasional involvement of the mother-in-law.

When asked about whether they themselves wanted to get an abortion, the answer was affirmative in 54 cases. In one case, since abortion was sought for economic reasons, the woman was ambivalent. In the remaining 15 cases, the woman herself did not want to undergo abortion, whereas the husband felt so in 13 cases. In nine cases neither wanted the abortion. Of the five cases, when a husband wanted an abortion and woman did not, the reasons were medical in three cases. In one case the husband wanted to remarry and in the other case the husband wanted his wife to get an abortion because the pregnancy was immediately after the marriage.

 

TABLE 3

Role of family in abortion

Famiy members

Known that woman is paegnant

Abortion decision by

Persons accompanying abortion

Persons supporting abortion

Self

1

51

Husband

69

57

52

50

Parents-in-law

50

4

8

12

Parents

16

-

16

4

Sister-in-law

19

1

7

1

Sister

4

1

4

Other relatives

1

7

* The responses to all the columns are multiple hence do not add to 70.

 

Of the 15 cases when women did not want an abortion, in 10 situations it was medically advised. In two cases, the husband insisted and in one case parents-in-law wanted a son. In two cases though the woman wanted to continue with the pregnancy, she underwent abortion because the family size was complete in one case; in the other she was in an embarrassing position as the pregnancy occurred because of sterilization failure.

 

 

It is clear that women do have a role in deciding whether to seek abortion or not. When discussing the role of parents (of woman) in decision making related to abortion, men unanimously reported ‘no role’. Further, it was pointed out that though sometimes women did go to their parents’ house post-abortion for rest, often-times they are not even informed.

The FGDs with men from both the villages indicate that husbands take decisions about abortion. Women are pressurized to say ‘yes’. Only if the number of children is high can the woman participate in the decision-making process. One mentioned, ‘Women here have not progressed so much that they will take the decision themselves.’

Abortion in general enjoys little societal approval. The overall opinion is that ‘couples should take precautions beforehand if they don’t want a child.’ Thus when the woman gets an unwanted pregnancy she feels embarrassed and ashamed. To decide about abortion she requires the support of the family, both morally and physically – accompanying her to the doctor for check-up and for the actual procedure. When she returns home from the hospital she needs rest and without the support from the family, especially women in the family, this is difficult. When she is away in the hospital she needs somebody to take care of the family. She also needs the family to overcome her feelings of guilt.

 

 

In 50 cases the husband’s support is positively acknowledged, without which it is difficult for women to go for abortion. In 18 cases everybody in the house supported the women and in 12 cases support of parents-in-law is mentioned. Here women perceive ‘support’ as ‘permission’ or ‘approval’ from the family. ‘If they (family members, especially mother-in-law and sister-in-law) don’t approve of abortion, how can I get the required rest? Who will look after my children when I am away in the hospital?’

Without family support or approval nobody will accompany her for abortion to the hospital. In 52 cases the husband accompanied his wife; in 24 cases the husband went alone whereas in 28 cases a female family member also went along with the husband. The woman’s mother (16) generally accompanied her more often than the mother-in-law (8) or other relatives. Interestingly, the woman’s relatives (mother or sister) accompanied her only in the case of abortion of female foetus (4 out of 8 cases of female foeticides), if the abortion was for medical reasons, or if the earlier child was too young. The mother-in-law accompanied the woman only twice.

Whether the signature of the husband is a pre-requisite for an abortion has been a focus of debate for sometime, even though the law does not so require. Signing the abortion form is seen as assuming responsibility for the action. In our study, the husband signed in 62 out of 70 cases. The views of the provider on why his signature is needed relate to practicality. The husband signs because in the event of a surgical procedure, the approval of a responsible relative is required. The common reaction of the private abortion provider is, ‘It is safe to get the signature of the husband, because if the abortion is sought without his knowledge, he often comes and disturbs us. We have our work to do rather than face an unnecessary drama.’ However, providers need to be more considerate and not insist on the husband’s signature in case the woman is accompanied by some other people.

Four women in this study sought repeat abortions, three women twice and one thrice. Repeat abortions al so indicate the support of the family – otherwise they would not be in any position to think of abortions over and over again.

 

 

Abortion involves expenses. Sometimes, abortion is not affordable as ready cash is not available. In such cases women continue with the unwanted pregnancy. The cost of an abortion includes travel, medicines and fees of the doctor. In this study only 39 women reported the cost of abortion. The range is very high; the costs vary from Rs 50 to 10,000. The most frequently reported cost is Rs 3000. It needs to be mentioned here that out of 70 abortions, 41 were conducted in private clinics in the city. Though the abortions were spread over a period of 17 years and the value of Rs 3000 varies over the period, spending this amount is difficult without the support of husband and family.

Terminating a pregnancy, creates trauma, whatever the method used. Not surprisingly, abortion related morbidity is high and if not in safe hands, abortion can even lead to mortality.

 

 

Traditionally, in the case of childbirth, the woman takes off at least five weeks for rest. We investigated whether women were advised rest a fter the abortion and whether they took it. In 48 cases rest was recommended and women followed the advice; not so in 15 cases. In the remaining cases no rest was advised. When the abortion procedure went off well, women reported resting for a day or two, or did ‘light’ housework with others ‘fetching water’ and ‘cooking’. Many women reported that since they worked in the field and the house, it was not possible for them to take more time off.

Information on resumption of sexual relations after abortion also indirectly indicates the husband’s support. As reported by 59 women, this period varied from 6 to 90 days. The most frequently reported answer was one month, with 49 women reporting one month and more.

Since abortion is not a procedure that everyone seeks, what do elders family members feel once it is over. The pattern of reactions is interesting. In 25 cases, the elders did not react to the abortion. In seven cases, it was reported that since there were no elderly people in the house, the question of seeking their permission did not arise. In three other cases, women hid the abortion from the elders in the house. In 13 cases, abortion was conducted after the consent of elders in the family so that there was no negative reaction. In four cases, the elders were upset after the abortion and reacted strongly. In one case the mother-in-law did not speak to the woman for four months. In one case elderly members criticized the couple, as they did not get along well. In eight other cases they felt bad about the abortion but did not get angry. One woman reported that since two of her earlier children were mentally challenged, and the mother-in-law was informed about the abortion, she did not face any problem in the house. In one case, where the couple went to Mumbai and underwent amniocentesis followed by abortion, they faced many post-abortion problems. Her parents-in-law did not approve of the abortion of female foetus saying, ‘We have everything, one more daughter wouldn’t have been a burden on us.’

 

 

The role of the family in abortions of ‘married’ and ‘not married’ women is qualitatively different. In the case of unmarried women, abortion enjoys little societal sanction. Still, if inevitable, it must be conducted whatever the cost. This is not the case with married women. Even when the pregnancy is undesired, women can continue with it and have a child. The reason for the pregnancy being unwanted is a crucial factor determining approval of the family and the society.

Women alone cannot decide on abortion. The husbands have a prominent role in decision-making. Most abortions among married women were sought for reasons of spacing between the children and for limiting the family. However, in all the FGDs with men and women, abortion of the female foetus emerged as the most common reason for abortion. Since son preference is strong among both men and women, both of them along with the earlier generation felt that a couple should have at least one son. Therefore, they do not think it wrong to undergo sex detection tests and abort the female foetus if the couple already has two or more daughters. Such abortion thus has social sanction and approval from the family, despite the risk associated with late abortions. Women also prefer to go for it expecting an improved status in the family, as highlighted by an educated rural respondent, ‘Making the family is a career for rural women and getting a son is an important milestone in the career.’

Our study shows that married women are generally not secretive about an unwanted pregnancy, indicating acceptance of abortion. In the case of abortion of female foetus too, women do not hide the fact from others. These cases involve more complex decisions since by the time the woman discovers the sex of the foetus, the pregnancy is already in the second trimester and the abortion carries greater risk. In all the cases the husband is the first person to be informed about the pregnancy, followed by the mother-in-law. However, once the couple decides about the abortion, the parents-in-law do not have much role in decision-making. Our study clearly shows that women do have a role in the decision-making process of abortion. Women feel that support of family members is necessary to go through the entire abortion procedure smoothly, which incidentally they did receive in most cases.

 

* The qualitative research on which this article is based was conducted under Abortion Assessment Project (AAP), India. It was funded by MacArthur Foundation and coordinated by HealthWatch Trust. The author thanks both these organizations.

 

References:

Bela Ganatra, 2000, ‘Abortion Research in India’, in Women’s Reproductive Health in India (eds.), Radhika Ramasubban and Shireen J. Jejeebhoy, 186-235.

M.E. Khan, Sandhya Barge and R. Chandrasekar, 1990, ‘Study of MTP Acceptors and Their Subsequent Contraceptive Use’. Journal of Family Welfare 26(3), 70-85.

R. Sinha, M.E. Khan, B.C. Patel, S. Lakhanpal and P. Khanna, 1998, ‘Decision Making in Acceptance and Seeking Abortion of Unwanted Pregnancies’. Paper presented at the International Workshop on Abortion Facilities and Post-abortion Care in the Context of the RCH Programme. New Delhi.

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