Expanding the Provider Base in India: The Feasibility of Provision of MA and MVA by non-MBBS Providers

Evidence supports task-sharing to expand the type of providers who can safely and effectively provide medical abortion services in India.

The Issue

Worldwide, an estimated 22 million unsafe abortions are performed each year. This is the result of a range of factors including the legal status and social stigma of abortion, and a lack of access to safe abortion services. In India, where abortion has been legal since 1971, shortages of equipped facilities and trained providers—particularly in rural areas—force many women to undergo unsafe procedures. This has contributed to high maternal mortality rates throughout the country, where rates of maternal deaths attributed to complications from unsafe abortions are as high as 8%.

The scarcity of skilled providers in India is mostly due to legal restrictions that prevent anyone other than obstetrician/gynecologists and those holding an MBBS degree who have been certified to provide abortion from performing abortion services. Expanding the number and type of providers able to legally perform abortion services, including manual vacuum aspiration (MVA) and medical abortion (MA), could greatly expand women’s access to safe abortion and save many lives each year.

To address this issue, Population Council researchers conducted two studies to assess the feasibility, safety, effectiveness, and acceptability of training nurses and, in the case of MA, Ayurveds (physicians trained in the Ayurveda system of medicine and holding a BAMS degree). The projects sought to produce the necessary evidence to advocate for a change in India’s legislation, allowing for a wider array of providers and greater access to safe abortion.

The Progress

While similar studies conducted elsewhere have demonstrated that nurses can safely provide first-trimester MA and MVA, the Population Council’s studies were the first of their kind in India. Moreover, whereas previous studies were performed in settings where non-physicians are legally permitted to provide abortion, this was not the case in India. Because of India’s legal restrictions related to abortion providers, researchers had to adopt creative study designs to collect the necessary evidence while abiding by the current law. 

Both the MA and MVA studies took place in the Indian states of Bihar and Jharkhand, yet their scopes differed slightly. Specifically:

  • The MVA study, conducted from 2008 to 2010, explored whether efficacy, safety, and acceptability rates associated with MVA provided by newly trained nurses were equivalent to MVA provided by physicians. The study enrolled 897 women who were no more than 10 weeks pregnant.
  • The MA study, conducted from 2006 to 2011, investigated whether assessments of client eligibility and completeness of abortion procedures by newly trained providers (i.e., Ayurveds and nurses) matched those of an experienced physician and whether MAs performed by these providers were as safe and effective as those done by MBBS physicians.

The MVA study was funded exclusively by the David and Lucile Packard Foundation in a grant made to the Population Council. The Swedish International Development Cooperation Agency (SIDA) and the Packard Foundation jointly provided funding for the MA project through a grant to the Consortium for Safe Abortions in India led by Ipas.

The Impact

The data generated by the MVA and MA studies provide the necessary evidence to support a proposed amendment to India’s Medical Termination of Pregnancy (MTP) Act that calls for expanding the provider base and allowing skilled, non-physician health care providers to provide abortion services. In addition, findings from the two studies have been provided to the Ministry of Health and Family Welfare and the research and program communities, helping to alleviate concerns about amending the MTP Act and widen support for provider expansion in India. Reproductive health advocates are currently seeking to amend India’s MTP laws and improve women’s access to safe abortion.

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