State of World Population Report: A case for action in the neglected crisis of unintended pregnancy
New Delhi, Mar 31: The State of World Population (SoWP) is an annual report published by the United Nations Population Fund (UNFPA), the sexual and reproductive health agency of the United Nations.
Each edition covers and analyses developments and trends in world population and demographics, as well as shedding light on specific regions, countries and population groups and the unique challenges they face. Each year, SoWP focuses on a particular theme and presents an in-depth analysis on the subject matter covered. The SoWP 2022 brings the spotlight to a critical theme: Expecting more: The preventable crisis of unintended pregnancy.
This note includes key insights from UNFPA's State of World Population Report 2022. To present the Indian scenario with respect to unintended pregnancies, family planning and comprehensive abortion care, findings from the National Family Health Survey (NFHS-5 2018-2019) and other available studies for India have been referenced.
A crisis unseen:
An unintended pregnancy is typically defined as one that is not wanted or one that is mistimed. Some unintended pregnancies will be celebrated. Others will end in abortion or miscarriage. An estimated 45 per cent of all abortions remain unsafe,1 these levels of abortion are also a public health emergency, hospitalizing about 7 million women a year globally, costing an estimated $553 million per year in treatment costs alone, and contributing to a significant share of all maternal morbidity and 4.7-13.2 per cent of all maternal deaths.2 In many respects, unintended pregnancy can be seen as a cause and result of gender discrimination. It often occurs because of gaps in gender equality and agency.
An unintended pregnancy is a personal issue, whether or not to become pregnant-is no choice at all; is a health issue, more than three in five (over 60 per cent of unintended pregnancies) end in abortion, many are unsafe abortions, one of the leading causes of maternal death and the reason for many more for hospitalizations per year; is a human rights issue-it is both a cause and an effect of gender discrimination and of restrictions on the agency and bodily autonomy of women and girls; is a humanitarian issue, often overlooked in crisis response, even though women in these situations are vulnerable to gender-based violence barriers and often face barriers to reproductive health services; is a development issue - While every country continues to experience unacceptably high rates of unintended pregnancy, we see strong correlations between rates of unintended pregnancy and lack of development.
The basic human right to determine freely and responsibly the number and the spacing of one's children has been recognized in numerous international human rights agreements over the past five decades.
One of the greatest public health achievements in recent history is expansion in the availability of effective, modern contraceptives. A world where every pregnancy is wanted. This aim is a central pillar of our mission at UNFPA. This report explores why so many pregnancies remain unplanned even as the widespread availability of modern contraception should make it possible for individuals and couples to exercise their right to decide when to have children.
Personal crisis, Nation's cost
Unintended pregnancies can result not only due to contraceptive failure and non-use of contraceptive services, but can also happen as a result of violence or coercion, and the vulnerability increases during crises and disasters. For others, pregnancy is a default rather than a deliberate choice.
The following can lead to unintended pregnancies:
She may be a victim of rape at home or by a stranger.
A young girl may lack information about how to avoid pregnancy because comprehensive
sexuality education is not offered in her school. She may assume pregnancy is a default option because she lacks opportunities and choices; without a chance to finish her education, for instance, she may not see a reason to postpone childbearing.
Contraceptives can be inaccessible, unaffordable or unavailable in a form that individuals would choose, fear or experience side effects from some methods.
Shame, stigma and fear may subvert the willingness to seek contraception.
Health providers may not be able or willing to give full choice or explain different methods.
Even if contraception is available and acceptable, women may not have the power to safely negotiate use with a partner.
Unintended pregnancies lead to cascading consequences and costs that last lifetimes-for mothers, children, families and communities. It can delay or discontinue women's/girls' education and/or workforce participation, impacting earnings and health. Unintended pregnancies cost health systems alone billions of dollars [according to studies conducted in the United States and Brazil], this can also be linked to negative social, mental and physical health consequences [including recourse to unsafe abortion] and increased vulnerability to poverty.
A Public health issue:
It is estimated that in 2015-2019 there were roughly 121 million unintended pregnancies in the world each year, and some 48 per cent of all pregnancies were unintended3, 61 percent of which ended in an induced abortion.4 The large proportion of unintended pregnancies that end in abortion - more than three in five
Out of all unintended pregnancies that happen each year globally, more than one in seven of these cases occurs in India6. Studies from India indicate that unintended pregnancy is associated with lower maternal health care utilisation and poorer infant and maternal health outcomes7 8 9. This highlights the criticality to focus on avoiding unintended pregnancies and consequently, complications during pregnancy and childbirth, and outcomes in terms of maternal and newborn health.
Adolescent pregnancy and choice:
Not all adolescent births result from unintended pregnancies, and in fact a majority of births among girls under age 18 take place among girls in a marriage or union, according to new research from the United Nations Population Division, suggesting that many of those pregnancies could be classified as intended.
Young girls' ability to decide when and with whom to have children is severely constrained. Thirteen per cent of all young women in developing countries began childbearing. Three-quarters of girls with a first birth at age 14 and younger had a second birth before turning 20, and 40 per cent of those with two births went on to have a third birth before turning 20.
Half of girls with a first birth between ages 15-17 had a second birth before turning 20. Furthermore, more than half of the additional births (after the first birth) to adolescent mothers were rapid repeat births; that is, they occurred within 24 months of a previous birth and came with exceptionally severe health risks for girls as well as their infants.
Unsafe abortion remains a cause of maternal mortality:
India's maternal mortality ratio (MMR) has improved to 103 in 2017-19, from 113 in 2016-18. This is according to the special bulletin on MMR released by the Registrar General of India on March 14, 2022. However, there is variation in MMR across various states. Seven Indian states have very high maternal mortality. These are Rajasthan, Uttar Pradesh, Madhya Pradesh, Chhattisgarh, Bihar, Odisha and Assam.
'Very high' MMR means 130 or more maternal deaths per 100,000 live births. Moreover, despite the legislative protection with the historic Medical Termination of Pregnancy Act of 1971, unsafe abortion remains the third leading cause of maternal mortality in India, and close to 8 women die from causes related to unsafe abortion each day12. In India, in 2007-2011, 67 per cent of abortions13 were classified as unsafe, varying widely across the states (range 45.1 per cent-78.3 per cent). There was a disproportionately higher risk of unsafe abortion among the vulnerable and disadvantaged populations including young women in India. Young women aged 15-19 were at the highest risk of dying from an abortion- related complication.
The MTP Act enacted in 1971 and the past and recent amendments, creates a conducive policy environment for abortion availed by all women, including adolescents and young people under prescribed circumstances and allows abortion for a wide range of conditions including for broad social or economic grounds. The Medical Termination of Pregnancy (Amendment) Act 2021 expands the access to safe and legal abortion services by reducing restrictions, such as opinion of one registered medical practitioner is needed for termination of pregnancy up to 20 weeks of gestation. It has also increased the upper gestation limit from 20 to 24 weeks for special categories of women such as survivors of rape, victims of incest, and others such as differently abled women and minors. With opinion of the state-level medical board, a pregnancy can also be terminated after 24 weeks in case of substantial foetal abnormalities. It also, allows termination of pregnancy beyond marital status in cases of failure of contraception used by a woman and her partner.
The way forward for India
Unintended pregnancies resulting in abortions, unwanted births and miscarriages are a key indicator of the need for expanding access to contraception services and information that support effective use. We must make pregnancy an aspiration not an inevitability, by empowering women and girls to make affirmative decisions about sexual activity and motherhood. Family planning and safe abortion are crucial tools in preventing maternal death.
Researchers at the Guttmacher Institute estimate that fully meeting women's contraceptive needs in lower- and middle-income countries and providing antenatal and neonatal care at World Health Organization-recommended levels, would reduce unintended pregnancies by 68 per cent, unsafe abortion by 72 per cent and reduce maternal deaths by 62 per cent.
Setting a new agenda and a supportive environment
The key priority for India is to address the unmet need for family planning/contraceptives and improve access to safe abortion services including medical methods. Expanding the reach and range of reversible contraceptives can prevent early pregnancy and pregnancies at short intervals jeopardizing maternal and newborn health. Informed choice and voluntarism in adopting contraceptives need to be the cornerstone of FP counselling. Contraception discontinuation, quality of care, lack of method availability, side effects, stigma and other factors contribute to users discontinuing a contraceptive method even while they still do not want to become pregnant. Data for method discontinuation, and further analysis is needed to understand the reasons for discontinuation and whether users are able to switch to other reliable methods.
Medical abortion can be provided in primary care settings, via telemedicine or self-managed - which offers an option for safe abortion.
To strengthen reproductive health services, and empower individual choices so that women and girls can exercise their right to bodily autonomy, the Government of India and development partners need to work together towards a new agenda for:
- Strengthening accessibility and availability of quality information and services for Long- Acting Reversible Contraceptive methods (LARC) in the country. Special focus is needed for improving young people's access to family planning information and contraceptives through intensifying Social and Behavior Change activities (SBC) for Family Planning and strengthening access to information and services.
- Exploring the possibility of expanding the current contraceptive basket by adding contraceptives such as subcutaneous hormonal injections, implants etc.
- Expanding and extending MPV strategies to high-focus states for delivering assured quality of services in the hardest-to-reach rural and urban areas.
- Increasing focus on improving the demand and uptake of post pregnancy contraception including Post-Partum IUCD, Post Abortion IUCD, Post-Partum sterilization, while ensuring quality of services.
- Strengthening concerted inter-sectoral convergence by active involvement of civil society organizations and leveraging community platforms under the Ayushman Bharat Yojana. And, utilizing other Sexual Reproductive Health (SRH) and health interventions to improve awareness on family planning, and to mobilize communities for improving contraceptive service uptake in hard-to-reach geographies and marginalized areas. Also ensuring continuity of essential FP and safe abortion services during emergencies, disasters, pandemics and in humanitarian settings.
- Making SRH services gender-responsive, stigma free and integrating health sector response to gender-based violence at all levels of SRH service delivery.
- Exploring new and positive ways of engaging men and boys, and family members to take more responsibility and to challenge existing social norms - including youth-centric interventions to increase uptake among the young population.
- Strengthening the capacity of primary health facilities to offer safe abortion services; improving providers' awareness about recent amendments in the MTP Act; and increasing women's awareness to seek safe abortion services.
Andrea Wojnar, UNFPA India Representative and Bhutan Country Director says that "India has made major inroads in terms of sexual and reproductive health and rights. The population is stabilizing, the number of preventable maternal deaths has reduced, and there is increased uptake of reversible and safe modern methods for family planning."
"However, the 2022 State of World Population Report brings to the fore the silent crises of unintended pregnancy...with more than one in seven cases of the 121 million cases worldwide, occurring in India.
In spite of safe, modern, and reversible contraceptives available, the most popular method remains female sterilization with its acceptance at 38 per cent15...sterilisation cannot delay or space pregnancies, which is important for preventing unintended or mistimed pregnancies, especially in the young population. What is also concerning is that 67 per cent of abortions have been classified as unsafe16...putting women and young girls at unnecessary risk."
"This is a wakeup call. India can lead the way in reversing these numbers. There is a need to invest in research to better understand the drivers and impacts of unintended pregnancy. Women and men - everyone - should have access to contraceptives that work for their bodies and circumstances. Sexual reproductive health services should be gender-responsive and stigma free. And addressing negative social norms should be the need of the hour."