availability, utilisation and health providers' attitudes towards safe abortion services in public health

156 Pages·2015·5.03 MB·English

AVAILABILITY, UTILISATION AND HEALTH PROVIDERS’
ATTITUDES TOWARDS SAFE ABORTION SERVICES IN PUBLIC
HEALTH FACILITIES OF SOUTH 24 PARGANAS, WEST BENGAL

DR. SOUVIK PYNE

Dissertation submitted in partial fulfillment of the
requirement for the award of the degree of
Master of Public Health

ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES & TECHNOLOGY
Thiruvananthapuram, Kerala. India – 695011

October 2015
AVAILABILITY, UTILISATION AND HEALTH PROVIDERS’
ATTITUDES TOWARDS SAFE ABORTION SERVICES IN PUBLIC
HEALTH FACILITIES OF SOUTH 24 PARGANAS, WEST BENGAL

DR. SOUVIK PYNE

Dissertation submitted in partial fulfillment of the
requirement for the award of
Master of Public Health

ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES &
TECHNOLOGY
Thiruvananthapuram, Kerala. India – 695011

October 2015
Dedicated to my beloved parents, Late Bijay Pyne and Smt. Manika Pyne.
Acknowledgements
Foremost, I would like to express my sincere gratitude to my guide Prof. (Dr.) T.K. Sundari
Ravindran, Professor, Achutha Menon Centre for Health Science Studies (AMCHSS) for her
constant support, motivation, patience, supervision and immense knowledge. Her guidance
helped me in all the time from conceptualising the research to writing the dissertation. It is a
great privilege to work under such an inspiration and I am really short of words to express
my thankfulness for her.
I am grateful to Dr. Mala Ramanathan, Dr. P. Sankara Sarma, Dr. Ravi Prasad Varma, Ms.
Jissa VT for helping me in my dissertation and Dr. K.R. Thankappan, Dr. V Raman Kutty,
Dr. Biju Soman, Dr. Kannan Srinivasan, Dr. Manju R Nair for their valuable comments to
improve my dissertation.
I am indebted to Dr. B Subha Sri (Rural Women’s Social Education Centre), Dr. Suchitra
Dalvie (Asia Safe Abortion Partnership), Dr. Sarika Chaturvedi (Karolinska Institutet,
Sweden), Mr. Sushanta K Banerjee (Ipas) for their precious inputs during the course of my
dissertation.
I thank Mr. Swapan Chattopadhyay (Ex-District Magistrate, South Dinajpur district, West
Bengal) for his immense help in personally forwarding my study permission application to
the Department of Health & Family Welfare, Government of West Bengal and facilitating in
procuring the permission for my study. I also thank Mr. Debasis Bose (Additional Secretary,
Department of Health & Family Welfare) for personally sending my permission letter and
Dr. Biswaranjan Satpati (Director of Health Services & EO Secretary, Department of Health
& Family Welfare) for granting me the permission to conduct the study. I am grateful to all
the officials and staffs of the Department of Health & Family Welfare, Government of West
Bengal who lend their co-operation by taking part in my study and/or facilitating it amidst
their busy working schedule all through my data collection.
I am thankful to my seniors Mr. Sanjeev Kumar Singh (MPH 2011) and Mr. Kirti Sundar
Sahu (MPH 2013) for guiding my journey to this institution and throughout it.
I extend my special thanks to other members of the adored Illuminati group (Dr. Aakshi
Kalra, Mr. Bevin Vinay Kumar, Mr. Peeyush) for their unending support, for the stimulating
discussions, for the critical coping strategies in difficult times, for the sleepless nights we
were working together before deadlines, and for all the fun we have had in the last two years.
I also thank Ms. Minu Abraham, Dr. Sanjay Babasaheb Bandgar, Ms. Pritty Titus, Dr. Tijo
George, Dr. Shreeporna Bhattacharya for their timely help whenever needed and other
colleagues for their encouragement.
I thank my friend Dr. Santanu Mukherjee for taking time out for doing many of my Bengali
translations of my study tools.
I am grateful to my dear friends Dr. Shubha Choudhury and Ms. Rinu PK for being with me
always and keeping my morale afloat.
I take this opportunity to acknowledge the blessings, love and care showered by God, my
father and my mother upon me in everything I did, without which I could have never
completed this work.
DECLARATION
I hereby declare that this dissertation titled “Availability, utilisation and health
providers’ attitudes towards safe abortion services in public health facilities of South
24 Parganas, West Bengal” is the bonafide record of my original field research. It has
not been submitted to any other university or institution for the award of any degree or
diploma. Information derived from the published or unpublished work of others has been
duly acknowledged in the text.

DR. SOUVIK PYNE
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences & Technology
Thiruvananthapuram, Kerala, India – 695011
October 2015
CERTIFICATE
Certified that the dissertation entitled “Availability, utilisation and health providers’
attitudes towards safe abortion services in public health facilities of South 24
Parganas, West Bengal” is a record of the original research work undertaken by Dr.
Souvik Pyne in partial fulfillment of the requirements for the award of the degree of
‘Master of Public Health’ under my guidance and supervision.

Dr. T.K. SUNDARI RAVINDRAN
Professor
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences & Technology
Thiruvananthapuram, Kerala, India – 695011
October 2015
Contents
Sections Topics Page no.
Abstract
1 Introduction
1.1. The international mandate for safe abortion services...................... 1
1.2. The need for safe abortion services................................................. 4
2 Literature review
2.1. Global scenario................................................................................ 6
2.1.1. Brief background.......................................................................... 6
2.1.2. Availability and access................................................................. 9
2.1.3. Utilisation..................................................................................... 12
2.1.4. Health providers’ attitude............................................................. 13
2.2. Indian scenario................................................................................ 15
2.2.1. Brief background.......................................................................... 15
2.2.2. Availability and access................................................................. 19
2.2.3. Utilisation..................................................................................... 26
2.2.4. Health providers’ attitude............................................................. 28
2.3. Need for the study........................................................................... 30
3 Methodology
3.1. Objectives........................................................................................ 31
3.2. Study design.................................................................................... 31
3.3. Study setting.................................................................................... 31
3.4. Sample size and sample selection procedures................................. 32
3.5. Operational definitions.................................................................... 35
3.6. Data collection techniques............................................................... 36
3.7. Data collection................................................................................. 37
3.8. Data storage..................................................................................... 38
3.9. Data analysis.................................................................................... 38
3.10. Ethical considerations...................................................................... 39
3.11. Dissemination of results.................................................................. 39
4 Results
4.1. Availability and utilisation of MTP services................................... 40
4.1.1. Results from facility survey......................................................... 40
4.1.2. District level records.................................................................... 53
4.2. Health providers’ attitude................................................................ 53
4.2.1. Characteristics of health providers............................................... 53
4.2.2. Attitude towards safe abortion..................................................... 55
4.2.3. Factors influencing attitude towards safe abortion....................... 56
4.3. Results from in-depth interviews.................................................... 58
4.3.1. Factors affecting provider choices in general............................... 59
4.3.2. Factors affecting availability and utilisation of MTP services..... 63
Sections Topics Page no.
5 Discussion and conclusion
5.1. Discussion........................................................................................ 79
5.2. Strengths of the study...................................................................... 85
5.3. Limitations of the study................................................................... 86
5.4. Conclusion....................................................................................... 87
5.5. Policy recommendations................................................................. 88
5.6. Further research............................................................................... 89
References
Annexes
Annexure I: Tables of utilisation records and factors affecting attitude towards safe
abortion
Annexure II: Informed consent forms
Annexure III: Study tools
Annexure IV: Study tool and Informed consent form (Bengali version)
Annexure V: Institutional Ethics Committee clearance letter
List of tables

Table no. Title Page no.
3.1 Details of facilities selected for facility survey............................................. 33
3.2 Characteristics of in-depth interview respondents........................................ 35
4.1 General characteristics of the health facilities............................................... 42
4.2 MTP related characteristics of the health facilities....................................... 44
4.3 Distribution of MTP availability across facility types.................................. 47
4.4 Distribution of MTP provision across facility types..................................... 48
4.5 Characteristics of MTP providing facilities.................................................. 50
4.6 Characteristics of MMA providing facilities................................................ 51
4.7 Utilisation patterns for surgical methods...................................................... 52
4.8 Social and demographic characteristics of health providers interviewed..... 54
4.9 Attitude scores and categories...................................................................... 55
4.10 Association between attitude and MTP providing status of health provider 58
5.1 Comparison of MTPs performed and evacuation of incomplete abortions.. 82

List of figures
Figure no. Title Page no.
4.1 Advertisement of MMA....................................................................... 73