International Journal of Gynecology and Obstetrics 118, Supplement 2 (2012) S113–S120 CONSEQUENCES OF UNSAFE ABORTION ON MORBIDITY AND MORTALITY Pathways and consequences of unsafe abortion: A comparison among women with complications after induced and spontaneous abortions in Madhya Pradesh, India Sushanta K. Banerjee a, *, Kathryn L. Andersen b , Janardan Warvadekar a a Ipas India, New Delhi, India b Ipas, Chapel Hill, NC, USA ARTICLE INFO ABSTRACT Keywords: India Induced abortion Postabortion complications Spontaneous abortion This study aimed to understand women’s pathways of seeking care for postabortion complications in Mad- hya Pradesh, India. The study recruited 786 women between July and November 2007. Data were collected on service provision, abortion-related complications, care-seeking behavior, knowledge about abortion legal- ity and availability, methods used, symptoms, referral source, and out-of-pocket costs. Women seeking care for complications from induced abortion followed more complex pathways to treatment than women with complications of spontaneous abortion. More complex pathways were associated with higher out-of-pocket costs. Improving community awareness on legal aspects, safe abortion methods, and trained providers are necessary to reduce morbidity associated with unsafe abortion. © 2012 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. 1. Introduction In 1971, the Indian parliament passed the Medical Termination of Pregnancy Act (MTP Act) enabling women to seek abortion across a range of situations: when the mother’s life is at risk or when her physical and mental health are compromised, or if the pregnancy is the result of rape or contraceptive failure, or is likely to result in fetal impairment. Unfortunately, this relatively liberal law has not led to significant reduction in unsafe abortion. Of 6.4 million induced abortions performed in India, 3.6 million (56%) are unsafe [1]. Complications of spontaneous abortion also contribute to maternal morbidity; an estimated 5% of pregnancies in India end in spontaneous abortion [2]. In all, there are approximately 10 000 to 12 000 deaths in India each year due to abortion-related complications [3]. In Madhya Pradesh, one of India’s largest states, safe abortion services are often not available at primary health centers, which serve as the first contact point for the largely rural population of 51 million. Only 3% of primary health centers and 19% of community health centers provide induced abortion services [4]. Stigma, lack of knowledge about safe services, and a paucity of accessible and trained providers often lead women to seek care from more convenient but unskilled providers who use unsafe abortion methods. This may have consequences as the likelihood of experiencing postabortion complications depends on the training and skill of the abortion provider, procedure used, and conditions under which the procedure is performed. * Corresponding author: Sushanta K. Banerjee, E-63 Vasant Marg, Vasant Vihar, New Delhi 110057, India. Tel.: +91 11 4606 8811. E-mail address: banerjees@ipas.org (S.K. Banerjee). 0020-7292/$ – see front matter © 2012 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. In India, few studies have examined the causal routes of postabortion complications, particularly by unqualified providers. A quantitative study of induced abortion in rural Bangladesh (a country with similar demographic characteristics) found that even when trained service providers are available, women often seek services from untrained providers and use clandestine methods that lead to increased morbidity, health service use, and cost [5]. No studies describing care-seeking behavior for spontaneous abortion complications were identified. Detailed information about common clandestine abortion methods used, types and severity of complications, and perceived symptoms or signs of complications has not been available for women in India. The purpose of the present study was to compare women with induced abortions with women with spontaneous abortions using the following factors: (1) types and symptoms of postabor- tion complications; (2) social and demographic characteristics and reproductive health history; (3) pathways of seeking services and treatment for abortion and postabortion complications; (4) type/profile of providers who offered abortion and postabortion services and treatment and management of postabortion complica- tions; and (5) consequences of postabortion complications in terms of symptom severity and cost. 2. Data and methods Women presenting to hospitals in 6 districts in Madhya Pradesh with postabortion complications were recruited prospectively. Five government-run medical college hospitals and 5 district hospitals were purposively selected as study sites because of their anticipated high caseload of abortion complications, geographic representation across the state, and institutional capacity for participation in