| Volume 7 Number 2 |
Biology and Society |
June 1990 |
| The Journal of the Galton Institute | ||
PSYCHO-SOCIAL FACTORS INFLUENCING DECISIONS TO ACCEPT TERMINATION OF PREGNANCY IN DELHI
N. N. SARKAR
Department of Reproductive Biology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 11029
Summary
Among women attending the MTP clinic of the National Institute of Health and Family Welfare, New Delhi during 1985-86, 135 were interviewed to ascertain the psychosocial factors influencing their decision to accept MTP. These women’s decisions to seek MTP appear to have been influenced by education, number of living children, and the family’s socioeconomic condition.
Introduction
As part of attempts in India to bring population growth under control, in 1971 the medical termination of pregnancy (MTP) Act came into force extending the right of women to have an abortion under proper conditions. Thereafter, studies of attitudes towards abortion1, social characteristics of women undergoing it2, and factor analyses of the decision process for acceptors of MTP3 were conducted to examine the effect of this legalization. Yet there are still reports that illegal abortions are being carried out.4,5 It is far from clear why women of rural India accept abortions in illegal circumstances and what the factors are that lead them to do so.4,5 On the other hand, it is also important to understand how city dwellers take advantage of the MTP Act. In metropolitan cities, if a pregnant woman decides to terminate her pregnancy legally, how does she make the decision, does she make it alone, or share ideas with her husband or other family members? What is her reasoning before choosing this procedure? These questions need to be answered.
The present study enquires how pregnant women decide to undergo MTP in the metropolitan city of Delhi.
Method
Women who attended the MTP clinic of the National Institute of Health and Family Welfare, New Delhi in 1985-86 were interviewed in the recovery room before leaving for home. A questionnaire was prepared in such a way that the answers could be cross checked. All questions were direct in nature, and the answers opened further conversation. Each interview usually commenced with a query on the state of the woman’s health, and ended with aftercare and contraceptive advice for the future. The statements of the woman about the number of children, type of contraceptive used, present age, monthly family income, educational status of both herself and husband, family structure, and ethnic belief were recorded.
The term nuclear family was employed here to mean husband, wife and children; joint family included either one or both in-laws (parents of husband) living with them; no other dependent or independent member in a joint family was considered in the study, because their relationship was not close enough for them to be concerned. Though the term "rhythm method" may not have been known to many spouses, in practice they were quite aware of it, so their practice of unprotected coitus but restricted with the intention of limiting family size was classified as "rhythm method". As to the type of contraceptive used, "any other methods" mainly included vasectomy of husbands and use in a few cases of foam, jelly or cream.
Of 135 women interviewed, 100 women who opted for MTP for the first time, and 32 women for whom it was the second time, were categorised as groups I and II respectively. Three women who accepted MTP for the third time were excluded as they formed a very small group.
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Table 1. |
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Percentage of women accepting MTP for the first time (Gr. I) and second time (Gr. II) in relation to the family status and attitude of other relations towards decision making process |
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Family status: attitude of relations |
Group I |
Group II |
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1. Nuclear Family |
66 |
78 |
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: Decision taken by |
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a) Wife alone |
40 |
37 |
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: Attitude of husband – Positive |
39 |
37 |
|
– Negative |
1 |
0 |
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b) In consultation with husband – Positive |
26 |
41 |
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2. Joint Family |
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: Decision taken by |
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a) Wife alone |
16 |
16 |
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: Attitude of husband – Positive |
16 |
1 |
|
: Attitude of in-laws – Positive |
10 |
6 |
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– Negative |
2 |
6 |
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– Indifferent |
4 |
4 |
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b) In consultation with husband |
18 |
6 |
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: Attitude of husband – Positive |
18 |
6 |
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: Attitude of in-laws – Positive |
11 |
6 |
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– Negative |
5 |
0 |
|
– Indifferent |
2 |
0 |
Results
In Group I the majority of women (74%) were 23 to 31 years of age, 14% 17 to 22 years old, and the remaining 12% 32-37 years of age. The corresponding percentages for group II were 72%, 0, and 28%.
Assessing the effect of the family (Table 1) the percentage of women of nuclear families who decided alone for MTP were similar in the two groups (40% and 37%). There was a slight but not significant excess of women in group II who took the decision in consultation with their husband. With a single exception in group I, all women in both groups had cordial co-operation from their husbands but, in spite of this, a percentage of women in joint families had to face resistance from their in-laws in the process of making the decision for MTP (2% in group I and 6% in group II). However, most of the in-laws expressed positive attitudes towards their daughter-in-law’s way of family planning. Thus, there is a trend of increasing awareness, among spouses and in-laws, of the need for family planning to cope with the fast changing socioeconomic conditions of metropolitan city life.
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Table 2. |
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Percentage of women accepting MTP for the first time (Gr. I) and for the second time (Gr.II) in relation to choice of contraceptive methods |
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Contraceptive methods |
Group I |
Group II |
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I Methods failure leading to MTP: |
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a) for spacing next child |
30 |
19 |
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– Rhythm method |
23 |
9.5 |
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– Condom |
4 |
9.5 |
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– Cu-T |
2 |
0 |
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– Oral pill |
1 |
0 |
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b) for limiting number of children |
70 |
81 |
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– Rhythm method |
50 |
31 |
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– Condom |
14 |
34 |
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– Cu-T |
2 |
10 |
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– Oral pill |
3 |
3 |
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– Any other methods* |
1 |
3 |
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II Methods chosen following MTP: |
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a) for spacing next child |
30 |
19 |
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– Rhythm method |
0 |
0 |
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– Condom |
4 |
0 |
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– Cu-T |
24 |
16 |
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– Oral pill |
0 |
0 |
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– Any other methods |
2 |
3 |
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b) for limiting number of children |
70 |
81 |
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– Rhythm method |
1 |
0 |
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– Condom |
4 |
12 |
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– Cu-T |
41 |
19 |
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– Oral pill |
0 |
3 |
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– Sterilization |
19 |
25 |
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– Any other methods* |
5 |
22 |
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* including vasectomy of husbands |
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As to the method of failure which led to MTP (Table 2), in the majority of cases the women used the rhythm method or condom. Regarding the choice of contraceptive following MTP, the majority of women intending to space the next child or to limit family size opted for Cu-T in both groups. Those intending to limit their family, however, included choice of other effective methods, sterilization or vasectomy of husband.
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Table 3. |
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Percentage of women accepting MTP for the first time (Gr. I) and for the second time (Gr. II) in relation to the educational status of wife and husband. |
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Educational |
Group I |
Group II |
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W |
H |
W |
H |
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Illiterate |
31.0 |
11.0 |
34.4 |
9.4 |
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Fifth |
11.0 |
9.0 |
9.4 |
6.2 |
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Eighth |
11.0 |
4.0 |
15.6 |
9.4 |
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Tenth |
7.0 |
13.0 |
3.1 |
9.4 |
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H-secondary |
21.0 |
33.0 |
21.9 |
34.4 |
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Graduate |
15.0 |
23.0 |
15.6 |
28.1 |
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Post-graduate |
4.0 |
7.0 |
– |
3.1 |
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Figure 2: Percentage of women accepting MTP for the first time (Gr. I) and second time (Gr. II) in relation to monthly family income. |
The groups differed in the number of living children (Figure 1); only 25% of women of group I and none of group II had one child; more women of group II had 2 (4 1%) or 3 (4 1%) children compared with 38% and 20% women respectively of group I. The distributions by monthly family income (Figure 2) were very similar in both groups. The percentage of women illiterate and educated only up to the eighth standard coming for MTP was higher than that of the husbands (Table 3). Above the 8th standard to postgraduate achievement, the percentage of women was lower than of the husbands in both groups. The latter difference suggests that there may be some influence of husband’s education on the wife’s decision to accept MTP. The distributions of women by occupation were very similar in groups I and II, and so were the distributions by religion. In both these variables the women in the sample conformed to the distribution in the city as a whole.
Discussion
This study shows that a proportion of women of reproductive age are willing to resort to MTP once or more than once to limit their family size, indicating their acceptance of a small family norm in conformity with the present national policy.6 Irrespective of educational standard of spouses, over 50 per cent of the women studied took the lead in the decision to seek MTP, almost all with the support of the husband showing their increasing self-confidence, foresight and rationality.3 These qualities were also apparent in the women who arrived at the decision despite in-laws’ opposition. Most of these women immediately after secondary education entered, through marriage, into family life, to perform the traditional Indian housekeeping and maternal roles, whereas the majority of men started earning to maintain their families, thus contributing the higher percentage of lower income group in this study.2,7 With the effect of rapidly changing economic conditions and city life, these couples with their difficult circumstances felt the urgency of family planning in view of the demands of bringing up and educating their offspring. This realisation appears to have allowed the women to accept MTP without feelings of guilt, ignoring the age-old religious stigma attaching to it in order to cope with the exigencies of the present age.
Acceptance of MTP by women to end an unwanted pregnancy that had resulted from failure of (mostly inefficient) contraceptive methods suggests a firm intention to restrict the number of children to be raised to the figure that the socioeconomic conditions of the family allowed, an intention supported by repeated MTP by women having two or three children.5 In spite of that intention, more women in group I preferred less effective methods prior to this MTP, possibly due to lack of motivation, ignorance or erroneous ideas about the side effects of the intra-uterine device, oral pill or sterilization,8 whereas the women’s tendency in group II to depend on more reliable contraceptive methods indicated a waning of their fear or ignorance, or their increasing experience and knowledge about contraceptives. However, the remarkable shift of the women’s choice from the rhythm method to condom, Cu-T or sterilization, following MTP in both groups indicated that any doubt that remained in their minds seemed to have disappeared with the brief counselling given by medical officers in attendance at the clinic during the preliminary examination before MTP; yet many women still preferred to remain with temporary rather than permanent methods of contraception even after completion of the desired family size.8 This suggests that they continue to fear loss of children, with the high infant mortality in India,9 or dislike the thought of being sterile at their prime age of reproduction, but were willing to attend MTP clinic if necessitated by method failure.8
In conclusion, besides education of the woman and her spouse, existing economic conditions and number of living children in the family appear to have influenced the wife’s decision to seek MTP, and these considerations may well be related to aspirations of comfort and status in the metropolitan city life of modern Delhi.
Acknowledgements
The author thanks the nursing staff and medical officers of the clinic for their kind co-operation, the Head of the Department of Reproductive Biomedicine and the Director of NIHFW for permission to carry out this study in their Institute, and the CSIR for financial support during this study.
References
1. Walvaker, V., Mallpur, A. M. and Palekar, B. S. (1973). An attitude study of 500 persons to abortion. J. Family Welfare 19, 30.
2. Goraya, R., Mohan, D., Agarwal, N., Takkar, D. and Hingorani, V. (1977). Some social characteristics of women undergoing medical termination of pregnancy. J. Family Welfare 23, 23.
3. Chaurasia, A. R. and Pathenkar, J. (1980). Factor analysis of decision process for acceptors of medical termination of pregnancy. J. Family Welfare 26, 48.
4. Nappasalai, J. R., Rajamahcswari, N. and Vijaya, R. (1984). Legal abortion — A care? Observation in a rural teaching hospital, Thanjavur, South India. J. Obstet. Gynaecol. India 34, 626.
5. Kandamuthan, M. (1986). Socio-demographic aspect of MTP cases in the SAT. Hospital, Trivandrum. J. Obstet. Gynaecol. India 36, 475.
6. Health and family welfare; In Seventh five year plan (1985-90), Government of India, Planning Commission, Vol. 2, Chap. II, p. 271.
7, Handbook on social welfare statistics (1986). Government of India, Ministry of Welfare, New Delhi, p.41.
8. Sarkar, N. N. and Narula, R. K. (1986). Characteristics of women accepting sterilization or IUD following MTP in a metropolitan city like Delhi. In Proceedings of International Conference on Voluntary Sterilization and Family Welfare, New Delhi, p. 167.
9. Health Information of India (1987). Ministry of Health and Family Welfare, Government of India, Nirman Bhavan, New Delhi, p. 42.