ABORTION PILLS AS OVER-THE-COUNTER DRUGS- A BOON OR A CURSE.
Globally induced abortion--safe or unsafe, legal or illegal--is a reproductive health service that is part of the lives of women, couples and communities in both developed and developing countries. When faced with unintended pregnancies, especially in contexts in which women lack access to effective family planning, induced abortion is an important part of women's reproductive health care.
Over the past decade in India, some key policy developments have contributed to improved availability, accessibility and safety of induced abortion services. These include revised regulations expanding services to primary health centres, the approval of medical abortion for terminating early pregnancies and the promotion of manual vacuum aspiration as the preferred method for early surgical abortion. The impact of these efforts has been dampened by difficulties in implementation. For example, the expansion of abortion services into lower level facilities has been uneven, leaving many districts with few public facilities that provide the services. Studies indicate that many of the largest, least developed states are disproportionately underserved by certified facilities.
Access to safe abortion services are the need of the current era, especially when 328 million women in India are in the reproductive age group (15-49 years), which constitute 26% of the total population of nearly 1.2 billion.  Approximately, 50% of the Indian population is below 25 years of age and more than 65% below 35 years.  The exact number of abortions conducted in India is not known, but it is estimated that nearly 6.7 million abortions are carried out every year and 8%-20% of all maternal deaths are due to unsafe abortion.  Of this, only one million are being carried out legally. 
WHO has laid down specific guidelines for safe abortions. WHO guidelines indicate the necessity of pre-abortion care for women requesting abortion to confirm pregnancy, to estimate the correct gestational age and to localise the site of pregnancy as either intra--or extra-uterine. Medical abortion is restricted for use in the early first trimester (upto 63 days), the dose being 200 mg of Mifepristone (oral) followed by 400 mcg of Misoprostol after 48 hours vaginally or orally for < 49 days. Between 49-63 days, mifepristone 200 mg orally and Misoprostol 800 mg vaginally or orally after 48 hours is recommended. Despite all these guidelines, abortion pills are widely being sold without medical prescription by the chemist over-the-counter. Self-medication is on the rise especially in rural areas, where access to medical services is poor.  Such unsupervised terminations can lead to hazardous effect on the health of women.
This study was carried out to find the consequences of self-administration of medical abortion pill by women to induce abortion.
MATERIALS AND METHODS
This retrospective observational study was conducted at the OB-Gynae department of MGM Medical College and Hospital, Jamshedpur. The study includes 164 women with history of self-medication with abortion pills. Self-administration means that these women did not visit any registered and trained medical practitioner or any health facility recognised to give medical abortion pill for consultation. Detailed history and examination was done, and ultrasound was done to confirm the diagnosis. The data collected included age of women, parity, marital status, literacy, gestational age at which abortion pill was taken, reason for admission to hospital, diagnosis, treatment received, need for blood transfusion and result.
During the study period of two years, 164 women who gave history of self-administration of medical abortion pills were admitted to our hospital with various complications.
Maximum number of patients belonged to 20-30 years (65.4%) [Table 1]. Only 10 patients (5.8%) were unmarried [Table 2]. 87 patients (53.3%) belonged to 2nd gravida [Table 3] and 83 patients (50.4%) took abortion pills at 8-12 weeks of gestation [Table 5]. 76 patients (46.3%) were illiterate (did not know to write her name or read any language) [Table 4]. 125 women (76.2%) presented with excessive bleeding with retained product of conceptus [Table 6]. Other common presentation was pain abdomen with signs of sepsis (fever, dehydration etc.), which was in 15% of the patients. Table 7 gives diagnosis or rather outcomes following abortion pills, which suggests 106 cases (64.6%) had incomplete abortion. 2 cases had ectopic pregnancy too. 101 patients presented with moderate anaemia, while 26 patients with haemoglobin level below 7 [Table 8]. Blood transfusion was required in 148 (90%) patients. Blood transfusion was done in those requiring surgical evacuation and in severely anaemic patients. Most of the patients, 118 patients (71.5%) required surgical evacuation and blood transfusion. Emergency laparotomy was done in 2 cases of ectopic pregnancy too [Table 9].
WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy, either by individuals without the necessary skills or in an environment that does not conform to minimum medical standards or both.  To decrease the incidence of unsafe abortion and thereby reduce maternal mortality ratio of country, MTP act was passed in 1971. 2002 Amendment of the MTP act legalised the use of mifepristone and misoprostol combination for termination of early pregnancy.  But this drug began to be used without medical consultation or without medical supervision due to over-the-counter availability and thus many untoward effects are observed in females taking these abortion pills.
In our study 68% women were multiparous which was similar to the study by Mishra et al,  also reported that 78% of women who had self-administered abortion pills were multiparous. This shows that women rely on medical abortion and consider it as a better method to space the birth rather than using contraception and preventing unwanted pregnancy in the first place.
50.4% of the patients in our study used the pills between 9-12 weeks of gestation and another 13.3% used it after 12 weeks, which was quite alarming. This late use of abortion pills clearly shows lack of knowledge regarding the medical abortion. Here education comes into play, but more importantly education regarding medical abortion. This is because both literate and illiterate patients consumed medical abortion pills without consultation or supervision. Illiterate % being 53.7 slightly higher than literate patients. These only shows lack of proper knowledge and education regarding abortion, be it in literate or illiterate patients. Studies indicate that the complications of second trimester medical abortion when compared with first trimester medical abortion are high with an increased risk of bleeding, sepsis and surgical evacuation.  Here also complications were seen more in women who had attempted second trimester abortion. Thus, it is very important to know or understand advantages and disadvantages of abortion in gestational periods.
In present study because of unsupervised medication and erratic drug schedule, 76.2% patients presented with excessive bleeding with retained products of conception. This finding corroborates with findings of Nivedita et al.  Signs of shock like fever, tachycardia etc. were present in 9% of cases. 8.8% complained only of pain abdomen or abdominal discomfort. These were mainly patients of missed abortion. Non-expulsion of products of conception was found in 3.4%. In our country where 59% of pregnant women are Anaemic,  excessive bleeding added fuel to the fire. In present study, 26 patients were severely anaemic on presentation which required immediate blood transfusion. 101 patients were moderately anaemic. Blood transfusion was mainly done in patients requiring surgical evacuation or laparotomy which amounted to 81% of cases.
In our study 60.6% of the patients had incomplete abortion, 21% had continued live pregnancy, 10.4% had missed abortion, complete abortion in 5% and ectopic pregnancy in 1%. 80.6% of cases require surgical evacuation. Ectopic pregnancy was treated with emergency laparotomy. Similar to our study, Nivedita et al  reported that the rate of incomplete abortion was 62.5% and failed abortion was 22.5% with 80% of these patients requiring surgical evacuation. In another study conducted by Thaker et al,  70.2% patients had incomplete abortion and 10.8% had failed abortion. 15.6% were treated by medical methods and rest were observed with blood transfusion given if required.
Another complication observed was septicaemia, which was observed in 15 cases (9%). These patients were managed with higher antibiotics and surgical evacuation.
Our hospital is one of the largest medical tertiary centres in the state of Jharkhand, which caters to large population daily. So, this study demonstrates the unwanted trend of consuming medical pills without supervision and thus exposing themselves to various complications.
This uprising trend has to be stopped and prevented from increasing, which can be done through proper knowledge first. Abortion, like most aspects of sexuality, is a taboo topic and rarely discussed. So, despite the legality of abortion in India and its provision by public facilities, most women are unaware that legal abortion services exist. At the same time, widespread media coverage and public information campaigns highlighting the illegal status of sex-determining ultrasounds and sex-selective abortions have led many women and some providers to believe that all abortions have been banned. So proper knowledge and education is a must.
Other methods have to be the supply of safe abortion services, improving the provision of safe medical abortion, addressing vulnerabilities among young and unmarried women and policy considerations. Jharkhand is a state with varying landscapes mostly located on Chota Nagpur plateau, so mainly a hilly state with mainly tribal population. These tribals have own culture and belief, so policy formulated should be made with them in mind and thus has to be acceptable to them. Here, means of transport have to be one of the basic necessities through which health services can be reached. There are a large number of villages to which access is quite difficult.
Prevention of unwanted pregnancy is the best way to prevent unsafe abortion. Every woman must be counselled regarding advantages, drawbacks, risks and limitations of different methods of abortion. Medical abortion is effective and safe when carried out under medical supervision.
Unsupervised use of medical abortion pills were associated with many complications like higher chances of incomplete abortion, failed abortion, haemorrhage leading to anaemia and needing blood transfusion, septic abortion and missed ectopic pregnancy. So over-the-counter sale of medical abortion pills should be restricted. Moreover, the need to educate women regarding the use of these drugs should be emphasised.
 Stillman M, Frost JJ, Singh S, et al. Abortion in India: a literature review. New York: Guttmacher Institute 2014.
 Census India SRS Bulletin. Registrar general of India, Govt. Of India 2013.
 Ministry of health and family welfare, comprehensive abortion care training and service delivery guidelines, New Delhi: Government of India, 2010.
 Johnston HB. Abortion practice in India: a review of literature. In: Johnston HB, (eds). Working Paper, abortion assesment project. 1st edn. Mumbai: centre for enquiry into health and allied themes (CEHAT); 2002:23.
 Santhya KG, Verma S. Induced abortion-the current scenario in India. In: Jejeebhoy SJ, (eds). Looking back, looking forward: a profile of sexual and reproductive health in India. Jawaharnagar, India: rawat Publications, 2004.
 WHO. The prevention and management of unsafe abortion. Report of a technical working group 1992. Available from: http://whqlibdoc.who.int/hq/1992/ WHO_MSM_92.5.pdf.
 Mishra N. Unprecedented use of medical abortion can be injurious to health. JEMDS 2013;2(8):856-9.
 Mentula MJ, Niinimaki M, Suhonen S, et al. Immediate adverse events after second trimester medical termination of pregnancy: results of a nationwide registry study. Hum Reprod 2011;26(4):927-32.
 Nivedita K, Fatima S. Is it safe to provide abortion pills over the counter? A study on outcome following self-medication with abortion pills. J Clin Diagn Res 2015;9(1):1-4.
 NFHS-3 National Family health survey. http://www.nfshindia.org.
 Thaker RV, Deliwala KJ, Sha PT. Self-medication of abortion pill: women's health in Jeopardy. NHLJ Med Sci 2014;3(1):26-31.
Manjula Srivastava (1), AnjaliSrivastava (2), Kumari Namrata (3)
(1) Assistant Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Medical College and Hospital.
(2) Associate Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Medical College and Hospital.
(3) Junior Resident, Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Medical College and Hospital.
'Financial or Other Competing Interest': None.
Submission 04-01-2018, Peer Review 31-01-2018, Acceptance 06-02-2018, Published 12-02-2018.
Corresponding Author: Dr. Manjula Srivastava, Duplex-12, Vasundara estate, NH-33, Near Irrigation Colony, Dinms, Jamshedpur-531018.
Table 1 Demography Age in Years No. of Cases % of Cases < 20 years 34 20.5% 20-30 years 107 65.4% > 30 years 23 14.1% Table 2 Marital Status No. of Cases % of Cases Married 154 94.2% Unmarried 10 5.8% Table 3 Gravida No. of Cases % of Cases 1 53 32.3% 2 87 53.3% >2 24 14.4% Table 4 Education No. of Cases % of Cases Literate 76 46.3% Illiterate 88 53.7% Table 5 Gestational Age at which Abortion Pills were taken Gestational Age No. of Cases % of Cases <8 weeks 60 36.3% 8-12 weeks 83 50.4% >12 weeks 21 13.3% Table 6 Complaints Complaints No. of Cases % of Cases Excessive bleeding with 125 76.2% retained products of conceptus Irregular bleeding with retained 4 2.6% products of conceptus Pain abdomen 14 8.8% Fever with pain and irregular 15 9% bleeding Non-expulsion products of 6 3.4% conceptus Table 7 Outcome of Abortion Pills Result No. of Cases % of Cases Incomplete abortion 106 64.6% Missed abortion 17 10.4% Failed abortion 34 21% (Live pregnancy) Complete abortion 5 3% Ectopic pregnancy 2 1% Table 8 Anaemia Classification Haemoglobin Levels No. of Cases % of Cases Mild anaemia (10-11) 37 22.6% Moderate anaemia (7-10) 101 61.4% Severe anaemia (<7) 26 16% Table 9 Management Treatment No. of Cases % of Cases Surgical evacuation 133 80.6% Medical methods 24 14.6% Observation 5 3% Laparotomy 2 1%
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Original Research Article|
|Author:||Srivastava, Manjula; Srivastava, Anjali; Namrata, Kumari|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Feb 12, 2018|
|Previous Article:||CLINICO-EPIDEMIOLOGICAL STUDY OF ORAL SQUAMOUS CELL CARCINOMA- A RETROSPECTIVE STUDY IN A TERTIARY CARE CENTRE IN CHENNAI.|
|Next Article:||A STUDY ON DETECTION OF GLYCOPEPTIDE RESISTANCE AMONG CLINICAL ISOLATES OF COAGULASE NEGATIVE STAPHYLOCOCCUS (CoNS) SPECIES IN A TERTIARY CARE CENTRE.|