Kalyanwala 2012

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Experiences of unmarried young

abortion-seekers in Bihar and
Jharkhand, India
a a
Shveta Kalyanwala , Shireen J. Jejeebhoy , A. J. Francis Zavier
a a
& Rajesh Kumar
a
Population Council , New Delhi , India
Published online: 14 Nov 2011.
To cite this article: Shveta Kalyanwala , Shireen J. Jejeebhoy , A. J. Francis Zavier & Rajesh Kumar
(2012) Experiences of unmarried young abortion-seekers in Bihar and Jharkhand, India , Culture,
Health & Sexuality: An International Journal for Research, Intervention and Care, 14:3, 241-255,
DOI: 10.1080/13691058.2011.619280
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Culture, Health & Sexuality
Vol. 14, No. 3, March 2012, 241–255
Experiences of unmarried young abortion-seekers in Bihar and

Jharkhand, India1
Shveta Kalyanwala*, Shireen J. Jejeebhoy, A.J. Francis Zavier and Rajesh Kumar
Population Council, New Delhi, India

(Received 7 April 2011; final version received 29 August 2011)
While several studies have documented the prevalence of unprotected pre-marital sex
among young people in India, little work has explored one of its likely consequences,
unintended pregnancy and abortion. This paper examines the experiences of 26

unmarried young abortion-seekers (aged 15 – 24) interviewed in depth as part of a
larger study of unmarried abortion-seekers at clinics run by an NGO in Bihar and
Jharkhand. Findings reveal that recognition of the unintended pregnancy was delayed
for many and many who suspected so further delayed acknowledging it. Once
recognised, most confided in the partner and, for the most part, partners were
supportive; a significant minority, including those who had experienced forced sex, did
not have partner support and delayed the abortion until the second trimester of
pregnancy. Family support was absent in most cases; where provided, it was largely to
protect the family reputation. Finally, unsuccessful attempts to terminate the pregnancy
were made by several young women, often with the help of partners or family member.
Findings call for programmes for young women and men, their potential partners,
parents and families and the health system that will collectively enable unmarried
young women to obtain safe abortions in a supportive environment.
Keywords: unintended pregnancy; abortion; pre-marital pregnancy; India
Introduction
Norms regarding pre-marital sex in India remain traditional and pre-marital sex is highly
stigmatised and discouraged, particularly among young women. Nevertheless, there
is evidence that significant minorities of young men and women have engaged in pre-
marital sex. A recent sub-national survey in six states suggests that pre-marital sex was
experienced by 15% of young men and 4% of young women aged 15 – 24. Large
proportions of young people who reported pre-marital relations had engaged in relations
with multiple partners (21 – 25%) and very few reported protected sex (13% and 3% of
young men and women, respectively) in all their sexual encounters (International Institute
for Population Sciences and Population Council 2010a), exposing young people to the risk
of infection, unintended pregnancy and abortion. While evidence of unintended pregnancy
and abortion among the young and the unmarried is limited, evidence from small facility-
based studies suggests that as many as 20 –30% of all abortions occurring in hospital
settings have occurred to adolescents (Ganatra 2000).
Little insight is available, however, on the experiences of unmarried abortion-seekers
in India, or the factors underlying these delays. Population-based investigations have not
*Corresponding author. Email: skalyanwala@popcouncil.org
ISSN 1369-1058 print/ISSN 1464-5351 online

q 2011 Taylor & Francis
http://dx.doi.org/10.1080/13691058.2011.619280
http://www.tandfonline.com
242 S. Kalyanwala et al.
succeeded in eliciting reliable responses; hence, in order to better understand the

experiences of unmarried young women in need of abortion, we conducted a facility-based
study, comprising both quantitative and qualitative elements, of unmarried young women
aged 15 –24 who sought abortion at the clinics of a non-governmental organisation (NGO)
in Bihar and Jharkhand. Our survey findings, presented elsewhere, highlighted several
significant obstacles to obtaining a timely abortion: failure to promptly recognise that they
were pregnant, fear of disclosure and the lack of partner support (Jejeebhoy et al. 2010;
Kalyanwala et al. 2010). The objective of this paper is to probe in greater depth the
experiences of unmarried young abortion-seekers and particularly the ways in which they
experienced various obstacles, including in recognising the pregnancy, obtaining partner
or family support and seeking an early pregnancy termination. Given the sensitivity of the
topic and the resulting limitations in the ability of survey data to shed light on why and
how questions, our analysis relies on in-depth interviews held with unmarried young
abortion-seekers and describes, notably, how young women recognised the unintended
pregnancy, the actions they took and the reactions of the partner and the family.
Background
Research on unintended pregnancy and abortion among the unmarried in India is sparse.
For example, the recent sub-national survey of young people in six states cited above
suggests that among those who reported engaging in pre-marital sex with a romantic
opposite-sex partner, 9% of young women and 4% of young men reported that they/their
partner had experienced a pregnancy; not all of these were terminated because marriage
ensued (International Institute for Population Sciences and Population Council 2010a).
A recent study of unmarried college students found that some 9% of sexually experienced
female students reported an unintended pregnancy and 17% of sexually experienced male
students reported that they had ever made a female pregnant; all of these pregnancies were
reported to have been terminated (Sujay 2009). Other studies conducted in facilities have
shown that large proportions of unmarried young abortion seekers delay their abortion
until into the second trimester (Aras, Pai, and Jain 1987; Bhatt 1978; Chhabra et al. 1988;
Divekar et al. 1979; Solapurkar and Sangam 1985).
Findings from several available studies have highlighted the vulnerability of
unmarried young abortion-seekers. Several clinic-based studies have reported that
unmarried adolescent abortion-seekers were more likely than other women to have
delayed their abortion into the second trimester (Aras, Pai, and Jain 1987). A similar
finding emerged from the survey conducted as part of this study and reported elsewhere:
one-quarter of unmarried young abortion seekers terminated their pregnancy in the second
trimester, compared to 9% of married young women; delays resulted from a combination
of such factors as delayed decision-making, fear of disclosure, lack of partner support and
unsuccessful previous attempts to terminate the pregnancy (Jejeebhoy et al. 2010;
Kalyanwala et al. 2010).
Study setting
Bihar and Jharkhand, the states in which this study was located, are considerably less
developed than the country on the whole on most development indicators, including the
proportion residing below the poverty line (40 – 41% versus 28%), literacy rates among
young women (43% and 50% in Bihar and Jharkhand, respectively, versus 68% in India as
a whole) and proportions residing in urban areas (11% and 22% in Bihar and Jharkhand,
Culture, Health & Sexuality 243
respectively, versus 28% in India as a whole) (Office of the Registrar General and Census
Commissioner 2001a, 2001b; Planning Commission India 2007). Access to safe abortion
services is also limited, with the two states reporting only 146 out of a total of 12,510
approved medical termination of pregnancy centres in India as of 2008 (Ministry of Health
and Family Welfare 2009).
Differences in pre-marital sexual experiences are less consistent. For example,
findings from a recent sub-national survey of young people in six states representing about
40% of India’s youth aged 15 – 24, including those from Bihar and Jharkhand, suggests
little difference in the extent of pre-marital sex: 14 –17% of young men and 3 –7% of
young women in Bihar and Jharkhand reported sexual experience, compared to 15% and
4% for all six states taken together (International Institute for Population Sciences and
Population Council 2010b). Among those who were sexually experienced, however,
unsafe and unwanted sex is more evident in Bihar and Jharkhand than in the six states
combined. While consistent condom use was limited, percentages so reporting ranged
from 6 –7% among young men in Bihar and Jharkhand to 13% among young men in all six
states; differences among young women were negligible (2 – 3%). While forced sex was
reported by large proportions of sexually experienced young women, it was far more likely
to be reported by young women in Bihar and Jharkhand than in the six states combined:
24% and 32% in Bihar and Jharkhand, respectively, compared to 18% for all six states
(International Institute for Population Sciences and Population Council 2009a, 2009b,
2010a, 2010b).
The study was located in the clinical settings of an NGO, Janani, a DKT International
affiliate. Janani provides family planning and reproductive health services through a
network of clinics in both Bihar and Jharkhand. Its clinics are registered under the Medical
Termination of Pregnancy Act to provide abortion and each clinic has at least one doctor
who is certified to provide abortion. Indeed, Janani is a major provider of abortion services
and conducts a large proportion of all abortions reported in Bihar and Jharkhand. Its clinics
are preferred to other health facilities by large numbers of poor women because they offer
reliable, confidential and high quality services and there are no hidden costs included
(drugs, tests, fees and so on).
Data and methods

The study was undertaken among young women seeking abortions during the period
November 2007 to December 2008. Given the difficulties experienced by population-
based studies in obtaining reliable data on unmarried abortion-seekers, we conducted
a descriptive and exploratory facility-based study to better understand both the
circumstances of pregnancy and the abortion seeking process. Because Janani does not
collect information on marital status from its abortion clients, but does collect
information on previous pregnancies and births, all young women aged 15 –24 who had
not had a previous pregnancy or had lost or aborted a previous pregnancy and had
not experienced a live birth, irrespective of marital status, were invited to participate
in the study. Their marital status was probed in the course of the survey
interview, both through direct questions and, at the end of the interview, through an
anonymous but linked envelope in which the young woman was asked to record her
marital status.
In this way, the survey covered a total of 549 unmarried young women (and 246
married young women). Survey interviews were conducted at the young woman’s
convenience, usually on the day of the abortion and prior to discharge.
Table 1. Socio-demographic characteristics and abortion-related experiences of unmarried women

who obtained an abortion at Janani clinics.
Sociodemographic characteristics/ Survey respondents In-depth interview
abortion-related experiences (%) respondents (n)
A. Sociodemographic characteristics
Mean age 19.5 19.1
Mean years of education 9.4 9.8
Currently in school/college 54.8 15
Worked for pay in last 12 20.9 5
months
Rural-urban residence
Urban 78.3 21
Rural 21.7 5
Resided 1.5 hours or further from the 25.9 9

Janani facility
B. Abortion-related Experiences*
Delayed pregnancy recognition till the third 17.3 4
month of pregnancy or later
Lack of support (emotional, financial, by
accompanying the respondent to the facility)
from:**
Family 51.7 19
Partner 26.8 9
Made at least one unsuccessful attempt 32.6 9
prior to arriving at the clinic
Pregnancy resulted from forced sex 17.5 7
Early pregnancy recognition and abortion decision, 23.5 7
prompt termination of pregnancy, directly from
NGO facility
Note: *Selection criteria for in-depth interview; **Multiple responses allowed.
Aside from the survey, the study also comprised a qualitative phase. In this phase, 26
unmarried adolescent and young women who had responded to the survey interview and
had acknowledged on direct questioning that they were unmarried, were invited to
participate in an in-depth interview. These young women were drawn from the largest four
facilities of the 16 from which survey respondents were recruited, namely Patna and Gaya
in Bihar and Ranchi and Jamshedpur in Jharkhand. Participants were selected purposively,
using a quota selection procedure that required five young women to be selected from each
of the following groups: those who delayed recognising the pregnancy till after the second
month of pregnancy; those reporting the lack of partner or family support in arriving at a
decision or seeking care; those who made at least one unsuccessful attempt prior to
arriving at the clinic; those reporting that the pregnancy had resulted from forced sex; and
those who reported that they recognised the pregnancy early and sought care promptly and
only from the NGO facility. While four of the five criteria reflected abortion-related
experiences, one, relating to those whose pregnancy had resulted from forced sex, was
included because we hypothesised that the forced status of these young women was likely
to influence their abortion-related experiences.
In-depth interviews were conducted in the week following their abortion, again at a
place selected by the young woman including the clinic itself, a park, a restaurant and,
very rarely, the young woman’s home. These interviews probed the circumstances of and
events leading to the termination of the pregnancy, including the nature of the sexual
relationship, recognition of the pregnancy, communication and decision-making

regarding abortion, steps taken once the pregnancy was recognised, family and partner
support, the quality of care obtained in each facility visited and so on. All interviews were
taped, transcribed and translated into English and transcripts were analysed using
Atlas Ti5.
We recognise that unintended pregnancy and abortion are particularly sensitive topics.
Consent-taking procedures were stringently observed. Consent was sought at several
points. First, when the adolescent presented at the clinic seeking an abortion, the clinic
staff member who conducted the initial screening briefly described the study and sought
her oral consent to be approached by a research assistant. If the young woman agreed, the
research assistant described the study to her in greater depth and then sought her consent,
along with her preference for when and where, following the abortion, the interview
should take place. Consent was sought a second time when administering the survey
questionnaire. If the young woman was selected for in-depth interview, consent was
sought at the end of the survey interview for this interview and, once again, a convenient
date and time was fixed. Again, before the in-depth interview, consent was taken. All
interviews were conducted with complete privacy and confidentiality and at a place that
assured auditory privacy. Investigators underwent intensive training in which they were
briefed about the study as well as the ethics of research, including confidentiality and
respect for the right of the respondent. The study was approved by the IRB of the
Population Council as well as Janani’s Ethical Review Committee.
Results
This paper focuses on the experiences of the 26 unmarried young women interviewed in
depth; however, in order to locate these respondents in the larger study from which they
were selected, we include relevant findings from the survey as well. Table 1 presents the
sociodemographic characteristics and abortion-related experiences of unmarried young
abortion-seekers who participated in the survey (n ¼ 549) and the 26 survey respondents
who were also interviewed in-depth. Appendix 1, Table A1 describes selected socio-
demographic correlates of unmarried young women who reported different abortion-
related experiences.
Socio-demographic profile
The 26 abortion-seekers interviewed in-depth were, on average, aged 19 years and had 10
years of education; most came from urban areas (21) and 9 resided 1.5 hours or further
from the Janani facility from which they accessed abortion services. At the time of the
interview, more than half were in school or college (15 out of 26) and 5 reported that they
had worked for pay during the last 12 months. These characteristics were fairly similar to
those observed among all survey respondents (see Table 1).
Panel B of Table 1 describes key abortion-related experiences, including those that
formed the basis for in-depth interview eligibility. Findings from the survey highlight that
17% did not recognise the pregnancy until in the third month; 52% and 27% did not
receive family and partner support, respectively; one-third made at least one unsuccessful
abortion attempt before reaching the qualified provider; and 18% reported that the
unintended pregnancy resulted from a non-consensual sexual encounter. In contrast, fewer
than one-quarter recognised their pregnancy and acted upon it swiftly and appropriately.
As evident from Table 1, the experiences of many young women placed them in more than
one category and as a result, more than the quota of five per category was achieved.
Recognition of unintended pregnancy

Our survey had found that, on average, unmarried young abortion seekers recognised their
pregnancy at 7 weeks of pregnancy, but terminated the pregnancy at 10 weeks on average.
Those who recognised their pregnancy late (after two months) were significantly younger
and less educated than those for who recognised their pregnancy promptly; they were also
more likely to have resided in rural areas and to have experienced forced sex, as seen in
Appendix 1, Table A1.
In in-depth interviews, as in the survey, most young women (22) had recognised the
pregnancy within two months of pregnancy. These young women recalled suspecting that
they were pregnant when they missed a period or experienced nausea or vomiting. Even
among them, however, several who suspected pregnancy convinced themselves to wait for
one or more months before taking action:
My periods used to come regularly every month. So, when they did not come this time, I told
him [partner] that I did not have my periods. I told him that I did not want to keep the child
now. (Sunita, 19 years, unmarried, currently not studying or working, Jharkhand)
When I did not get them [period], I told him [boyfriend] that one month had passed and I have
not got my periods and that I was scared I was pregnant. So he said we should get a check-up
done immediately. (Mary, 18 years, unmarried, currently studying, underwent first trimester
abortion, Jharkhand)
Four young women had not recognised their pregnancy until the third month of pregnancy
or later. Among them, two had experienced forced sex and their narratives reveal that
awareness about conception or pregnancy was so limited that it was their employer and
mother, respectively, who first raised the possibility of pregnancy based on the signs and
symptoms, including nausea and vomiting, shown by the respondent:
When I did not have my periods, I did not even think that I could have conceived. I did not feel
anything and did not feel like telling this to anyone. But one day my employer asked me why
my stomach was looking so big. She also asked me to lift my kurta and show her my stomach.
That evening I told her what I was feeling and that I had not had my periods for 2 – 3 months,
and she told me where to go. (Komal, 20 years, unmarried, not educated, currently working,
experienced forced sex, underwent second trimester abortion, Bihar)
I started having a vomiting sensation. I had no idea that your periods stop when you conceive a
child. I started vomiting and my mother asked me when I had my last period. I told her that I
had not had them for the last three months. Then my mother asked me what had happened with
me and what had I done. When she asked me, I told her everything. (Najma, 18 years,
unmarried, currently not studying or working, experienced forced sex, underwent second
trimester abortion, Bihar)
Recognising and acting upon the realisation of an unintended pregnancy therefore were
perhaps the first obstacle young women faced in the course of seeking pregnancy
termination.
Parental/family reactions and support

Once the pregnancy was recognised, the typical reaction was one of fear or anxiety and
concerns about loss of reputation if information about the pregnancy were disclosed at
family and community levels. Indeed, a majority of the survey respondents reported fear or
anxiety (89%) and sociodemographic variation was mild (not shown in tabular form). This
reaction was, similarly, reiterated by all 26 young women interviewed in depth. Many
young women reported their concerns about disappointing their family or breaking the
trust of their parents; others feared physical violence, verbal abuse or imposition of
restrictions on their freedom of movement. For example:
Their view towards me would have been shattered because I belong to a Brahmin family
where we treat a girl like Sita. My parents have full faith in me but had they come to know
about this [pregnancy], they would have lost this trust in me. They would have asked me to
leave my studies . . . my reputation would have been spoiled in their eyes. (Binita, 20 years,
unmarried, college going, underwent first trimester abortion, Jharkhand)
It was not possible for me to tell anyone about this [pregnancy], as I belong to a middle class
family and they would blame me for all this. Moreover, I do not have this kind of relationship
with my parents that I could tell them all this frankly. . . . If I told any of my friends, they
would also think wrong things about me. (Mary, 18 years, unmarried, currently studying,
underwent first trimester abortion, Jharkhand)
As a result, as many as 19 out of 26 in-depth interview respondents had not disclosed their
pregnancy to a parent or a family member. Just seven had disclosed their pregnancy (in the
survey, 28% had disclosed the pregnancy to their mother and 25% to other female relatives
[not shown in tabular form]) and all seven of these young women reported that the initial
reaction was indeed one of anger and even violence, and a concern for bringing shame to
the family:
. . . When my parents got to know about it [pregnancy], my father beat me up with a belt,
shoes or whatever came in his hands. My mother taunted me and asked if I was still interested
in talking to that boy. (Jyoti, 17 years, unmarried, currently not studying or working,
underwent first trimester abortion, Bihar)
The seven young women whose pregnancy had resulted from a forced sexual encounter
also received little sympathy. Indeed, among them too, the typical reaction from family
members was anger and violence; indeed, young women reported that they had been
accused of having provoked the incident:
When my mother got to know, she scolded me. She slapped me twice and said a lot of things.
She said that why did I do all this with a servant. I told her that I have not done it deliberately;
it was done by him forcibly. (Meena, 15 years, unmarried, currently studying, experienced
forced sex, underwent second trimester abortion, Bihar)
When my mother got to know, she abused me and continues to do so even now. My brother
and sister have stopped talking to me. (Vimla, 18 years, unmarried, currently not studying or
working, experienced forced sex, underwent second trimester abortion, Jharkhand)
I did not tell my parents but my aunt came to know that I was pregnant. Since then she does
not respect, love or show affection to me. She thinks I have done this with my boyfriend and
that I have let her down in the society. . . . What can I do if she thinks like this? But from my
point of view, my elder father [uncle] who has lost his respect. (Rosy, 22 years, unmarried,
currently studying at home, experienced forced sex, underwent second trimester abortion,
Jharkhand)
Although family reactions were typically unsympathetic, family members of all seven
young women who had informed a family member reported that once informed about the
pregnancy, family members did indeed provide monetary support or accompanied the
young woman to the clinic (48% of survey respondents so reported). Interestingly, older,
better educated and urban respondents and those who had experienced forced sex were
significantly less likely than others to have disclosed their pregnancy status to a family
member or received support when disclosed, as evident from Appendix 1, Table A1.
Young women interviewed in-depth responded thus:
When my cousin got to know about this [pregnancy], first of all he got angry but then later said
that there was no need of getting angry instead this problem should be solved soon now. He
said that we should go somewhere and he will help me as much as he can. (Alka, 20 years,
unmarried, currently studying, underwent first trimester abortion, Bihar)
Yes my uncle and parents supported me in getting the abortion done. My father gave the
money there. (Jyoti, 17 years, currently not studying or working, underwent first trimester
abortion, Bihar)
Partner reaction and support

Lack of partner support was reported by many fewer women: 9 of 26 reported that they had
not disclosed their pregnancy status to their partner or, if disclosed, had not received
support from him. Young women’s narratives confirm that the partner was more likely
than any other individual to have provided support. Young women interviewed in-depth
described partner support in many ways: they arrived at the decision to terminate the
pregnancy together with the respondent, provided emotional support, accompanied the
young women to the facility and arranged to cover the costs of the abortion.
These 17 young women described discussing the unintended pregnancy with their
partner and arriving at a decision together with the partner about terminating the pregnancy.
For example:
We both took this decision [to abort] together. I asked him [boyfriend] if we were doing right
by aborting our child who is our own blood. He then explained to me that if we cannot bring
up our child well, then what is the point in having a child? (Preeti, 19 years, unmarried,
currently working, underwent first trimester abortion, Bihar)
I took the decision to abort myself. I convinced my partner that since we could not get married
now, we should abort this pregnancy. (Nafisa, 23 years, unmarried, currently studying,
underwent first trimester abortion, Bihar)
We had discussed that I would get my check-up done and then go for an abortion. . . . We had
decided this because I have not completed my graduation yet. I went with him [boyfriend] to
the hospital. (Pramela, 22 years, unmarried, currently studying, underwent second trimester
I asked him [boyfriend] how we could keep this child now because we are still unmarried and
what would everyone think about us. I told him that first of all we should finish our studies and
he agreed. (Martha, 22 years, unmarried, currently not studying or working, underwent first
trimester abortion, Jharkhand)
Aside from supporting the young woman to arrive at a decision, all 17 young women
reported that the partner had provided emotional and financial support. While 14 young
women reported that the partner had also accompanied them to the Janani facility, the
remaining three reported that the partner was out of town at the time of the abortion, but
had arranged for the young woman to be accompanied to the facility by a friend or sibling
and had provided financial support. Narratives highlight the comfort young women
derived from the presence of their partner at the facility at the time of abortion and the
difficulty that the partner had faced in arranging the money for the abortion. For example:
I told him [boyfriend] when I did not get my periods on time. He said that he is with me in this
problem and will help me solve that. (Alka, 20 years, unmarried, college going, underwent
first trimester abortion, Bihar)
He gave me 100% support. At the time of abortion my boyfriend was with me. Even when
I was talking to the doctor he was there as I always feel comfortable with him, like my
husband. Earlier I was feeling very scared about the money that would be spent on getting it
[abortion] done. But then I thought that abortion had to be done at any cost, so I decided that I
would arrange the money from somewhere. My boyfriend gave the money. (Manisha, 23
years, unmarried, currently studying, underwent first trimester abortion, Bihar)
My boyfriend gave all the money. But he faced problems in arranging the money. The money
was short so he had gone again to his friend to borrow money. He borrowed Rs. 400 from his
friend. (Sunila, 22 years, unmarried, currently working, underwent first trimester abortion,
Jharkhand)
In contrast, nine young women reported that the partner had been unsupportive. Four of
these young women had experienced a forced sexual experience and therefore seeking
partner support was not an option for them. Among others, young women reported, for
example, that the partner had refused to accept the responsibility, had doubted her fidelity,
had moved away or had married someone else. Almost all of these young women
underwent abortion in the second trimester:

When I told him [boyfriend], he said how this could happen by doing it [sexual intercourse]
once? He would not believe it and said that I was lying. He [boyfriend] refused to accept this
pregnancy and did not support me. Then she [friend] only took me to the clinic. (Nisha, 18
years, unmarried, currently studying, underwent second trimester abortion, Jharkhand)
He [boyfriend] asked me to get the abortion done. He did not give any money to me nor did he
help me in any way. My sister’s husband gave the money that was spent here. (Reema, 15
years, unmarried, currently working, experienced forced sex, underwent second trimester
Two out of these nine young women had not informed the partner or a family member
about the pregnancy and therefore received no support at all. One lived with her uncle and
aunt and had experienced forced sex, the second, who lived with her parents, had not
informed her partner. Both attended the Janani clinic unaccompanied:
I didn’t have the money [for the abortion], I took a loan from my employer. I told her that
I needed to go to the village so I needed the money. I asked for Rs1000 or Rs.1500 but she said
that she just had Rs.700. So I took that much only. I was also tense about how I would repay
this amount later. (Komal, 20 years, unmarried, illiterate, currently working, experienced
forced sex, underwent second trimester abortion, Bihar)
Survey data confirm that those who did not receive partner support were significantly more
likely than others to be young and poorly educated and, as expected, more likely to have
experienced forced sex, as evident from Appendix 1, Table A1.
Unsuccessful previous attempts

On average, there was a lag of almost one month between the time of recognition of the
pregnancy and the time of accessing abortion services at Janani, a finding observed in both
the survey and among in-depth interview participants. One of the most common reasons for
the lag was the fact that many young women attempted unsuccessfully to terminate their
pregnancy, largely by approaching a chemist, a nurse or other uncertified provider. As
mentioned earlier, 33% of survey respondents had made at least one unsuccessful attempt
prior to coming to Janani facility, irrespective of age, education, work status, rural-urban
residence and the extent to which the episode that resulted in the unintended pregnancy was
forced.
At least one unsuccessful attempt to terminate the pregnancy was reported by 9 of 26
in-depth interview participants. For the most part, previous attempts to terminate
pregnancy were conducted by way of oral preparations; by far the most widely accessed
provider was a chemist. As many as 78% of survey respondents (not shown in tabular
form) and seven of nine in-depth interview participants who had made a previous
unsuccessful attempt to terminate their pregnancy obtained medication from a chemist.
Most respondents reported that the partner, a family member or a friend from whom advice
was sought was aware of over the counter medication for abortion. We do not know the
exact nature of medicines given by the chemist, but the interviews indicate that whatever
the medication, it failed to bring on the missed period or terminate the pregnancy,
potentially resulting in delays in accessing abortion services at a certified facility. Also
evident was that young women were largely unaware of the type of medication taken and
that most were unaware of the correct dosage or signs that abortion was underway. Young
women described their efforts as follows:
I was late in coming to Surya because I was trying something or the other at home to get rid of
this [pregnancy]. I tried homeopathic medicines but nothing happened with that. . . . It was to
be taken for three days; I think its name was Mensolex . . . . . . I didn’t get it myself; my
boyfriend got that for me. But nothing happened with that. (Deepti, 20 years, unmarried,
currently studying, underwent first trimester abortion, Bihar)
My father got three tablets each cost Rs. 300 . . . I had all of them together. . . . I don’t know
from where he got these medicines – from a doctor or elsewhere. My mother gave it to me and
asked me to have it and said that this will finish the problem. But nothing happened. (Jyoti,
17 years, unmarried, currently not studying, underwent first trimester abortion, Bihar)
He [boyfriend] said that the child is not very big yet so it can be aborted by just the medicine.
Then I took the medicine that he had bought from the chemist. After taking that I had my
period but I didn’t know whether the amount was too little or what. But then the next month it
[periods] didn’t come again. I told him [boyfriend] and he asked me to wait for another month
and observe. Then the next month also I didn’t have my periods and when I told him, he said
that he was also confused. (Preeti, 19 years, unmarried, currently working, underwent second
trimester abortion, Bihar)
I took four tablets after 15 – 20 days of missing my periods. . . . My boyfriend got those for
me. . . . No, I do not remember the name of the medicine but nothing happened. (Ratna,
22 years, unmarried, currently working, underwent first trimester abortion, Jharkhand)
Just two young women had obtained services previously from healthcare providers: a
homoeopath and a doctor, respectively. These providers attempted to terminate the
pregnancy using oral medication and even these young women were unaware of the name
of the medication taken or the correct dosage to be taken. For example:
I went to the doctor with my mother. She [mother] gave me the medicines which I took for
two- three days and when there was no effect of that on my periods then an ultra sound was
done because he [doctor] thought that there might be a tumour, but when it was done
everything was known [that she was pregnant].” (Meena, 15 years, unmarried, currently
studying, underwent second trimester abortion, experienced forced sex, Bihar)
Early pregnancy recognition and prompt and appropriate care

As evident from Table 1, the pathway to abortion for seven respondents was smoother.
They recognised the pregnancy early and sought an abortion from the Janani facility
promptly and directly. For example:
When my periods stopped, I had a doubt and went to the Janani clinic immediately for a
check-up. I got to know about that [my pregnancy]and had the abortion. (Manisha,
23, unmarried, currently studying, underwent first trimester abortion, Bihar)
When my periods did not come, then I had a doubt. When the whole of December went by and
January started, I thought that there must be some problem. I just felt that I was pregnant and
went immediately to Janani clinic for a check-up, and then had the abortion. (Shilpi, 16 years,
unmarried, currently not studying, underwent first trimester abortion, Jharkhand)
As suggested in Appendix 1, Table A1, these young women were significantly more likely
than others to be aged 20 –24, highly educated and reside in urban areas and significantly
less likely to have experienced forced sex. They were also more likely than others to have
supportive partners (not shown in tabular form).
Discussion
The objective of this paper was to explore in-depth the pathways unmarried young women
took in order to terminate an unintended pregnancy, using narratives of young women who
had successfully terminated their unintended pregnancy at a certified facility. Our findings
highlight the vulnerability of young women. First, for the most part, partners were indeed
supportive and took responsibility for their girlfriend’s situation. They participated in the
decision to terminate the pregnancy, they provided emotional support, they accompanied
the young woman to the facility, helped her obtain medication, although inappropriate, to
terminate the pregnancy without attending a facility and arranged to pay for the abortion.
A significant minority, including those who had experienced forced sex, did not have
partner support and most of these young women had, perhaps as a consequence, delayed
the abortion until they were in their second trimester of pregnancy. Second, parental and
family support was absent in most cases. Many young women feared revealing their
situation to their parents and family members and those who did so faced family ire; where
support was provided, it was largely to ensure that the young woman terminated her
pregnancy and did not bring disrepute to the family. Third, awareness and
acknowledgement of the unintended pregnancy were far from universal: most young
women did not recognise immediately that they were pregnant and many who suspected so
did not acknowledge it even to themselves until a further month had passed; at the same
time, a significant minority did not recognise the pregnancy till the third month of
gestation. Fourth, there was a general lack of awareness among young women, partners
and family members of qualified providers and appropriate methods of abortion. Indeed,
many young women (on their own or with the help of a partner or family member) made
unsuccessful attempts to terminate the pregnancy by approaching unqualified providers or
taking inappropriate medication or the mifepristone-misoprostol combination incorrectly.
Our narratives suggest that in many cases it was a supportive partner or a family member
who obtained medication for the young woman, suggesting again that not only young
women, but also their partner and family members were misinformed about effective oral
medication and the correct use of this medication. Finally, we note that, notwithstanding
the obstacles faced by the majority in obtaining their abortion, there was a significant
minority who recognised and acted upon the unintended pregnancy promptly and
appropriately. Compared to other women, these young women were older and better
educated, more likely to come from urban areas, less likely to have experienced forced sex
and more likely to report partner support.
We acknowledge that our findings cannot be generalised to all young abortion-seekers
in the two states. We had opted for a facility-based study because community-based
studies in India have not been successful in providing reliable information on abortion-
seeking among the unmarried. Hence we may have missed abortion-seekers who
terminated their pregnancy by different means. Indeed, the study excludes young women
who may have successfully aborted by taking the mifepristone-misoprostol combination
obtained from a chemist shop or who may have obtained abortion from an untrained
provider or other abortion providing facilities or, indeed, may have been unsuccessful in
terminating the unintended pregnancy and had to carry it to term. Moreover, even though
our respondents had an opportunity to report their marital status anonymously, some
unmarried respondents may have concealed their status and their experiences would not be
included in this study. Finally, because we focused on young women and adolescents who
had no previous pregnancy or had terminated any previous pregnancies, our findings are
not representative of abortion seekers in general.
Findings provide a number of directions for programmes. At the individual level, it is
important that young women and young men, their potential partners, are appropriately
informed about the signs and symptoms of pregnancy, contraceptive options and, in case
of unintended pregnancy, their rights on the one hand and methods and services available
to them on the other. While young men were, for the most part supportive, efforts must be
made to sensitise young men about sexual coercion and their responsibilities in practising
contraception, on the one hand, and in supporting their partner in case of an unintended
pregnancy, on the other. At parent and community level, parents, family members and
community gate-keepers must, at the same time, be encouraged to ensure a more open and
supportive relationship with young people, including if unintended pregnancy is
experienced; parents must be sensitised about the fears and sense of isolation and
helplessness that young women who experience an unintended pregnancy face and the
need to support rather than censure them in their pathway to abortion. At health system
level, youth-centred programmes and services are needed that are sensitive to issues of
pre-marital sex, including sexual coercion, unintended pregnancy and the need for
abortion among the young. Providers must be trained to understand the provisions of the
law with regard to the rights of the unmarried to secure abortion and about women’s right
to obtain abortion confidentially; efforts must also be made to ensure that providers do not
stigmatise the unmarried, that they maintain their confidentiality and that they provide
them sensitive counselling and non-judgemental services. At policy level, findings
highlight the need to recognise unmarried young women as a highly vulnerable group and
ensure the realisation of their right to obtain safe abortion services including safe second
trimester abortion services.
Acknowledgements
This project was supported by a grant to the Population Council from the Hewlett Foundation and a
grant to the Consortium for Comprehensive Abortion Care from the Packard Foundation and the
Swedish International Development Agency (Sida). Their support is gratefully acknowledged. We
are grateful to M.A. Jose and Komal Saxena for their support in preparing the paper and to Anupa
Burman, Rakhi Burman, Preeti Verma and our investigator team for their sensitive and sincere
efforts at eliciting information on these difficult topics. We would also like to record our deep
appreciation to our young study participants, who so willingly gave us their time and shared their
personal experiences with us.
Note
1. An earlier version of the paper was presented at the 1st Conference of the Asian Population
Association, 16 – 20 November 2010, at Vigyan Bhawan, New Delhi.
References
Aras, R., N.P. Pai, and S.G. Jain. 1987. Termination of pregnancy in adolescents. Journal of
Postgraduate Medicine 33, no. 3: 120– 4.
Bhatt, R.V. 1978. An Indian study of the psychosocial behaviour of pregnant teenage women.
Journal of Reproductive Medicine 21, no. 4: 275– 8.
Chhabra, R., N. Gupte, A. Mehta, and A. Shende. 1988. MTP and concurrent contraceptive adoption
in rural India. Studies in Family Planning 19, no. 4: 244– 7.
Divekar, S.A., G. Natarajan, A.C. Ganguli, and V.N. Purandare. 1979. Abortion in unmarried girls.
Health and Population – Perspectives and Issues 4: 308– 21.
Ganatra, B. 2000. Abortion research in India: What we know and what we need to know. In Women’s
reproductive health in India, ed. R. Ramasubban and S. Jejeebhoy, 186– 235. Jaipur, India:
Rawat Publications.
International Institute for Population Sciences and Population Council. 2009a. Romance and sex
before marriage among young women and men in Bihar: Youth in India: Situation and needs
2006– 2007, Policy Brief No. 19. Mumbai: Author.
International Institute for Population Sciences and Population Council. 2009b. Romance and sex
before marriage among young women and men in Jharkhand: Youth in India: Situation and
Needs 2006– 2007, Policy Brief No. 10. Mumbai: Author.
International Institute for Population Sciences and Population Council. 2010a. Youth in India:
Situation and needs 2006–2007. Mumbai: Author.
International Institute for Population Sciences and Population Council. 2010b. Romance and sex
before marriage among young women and men in India: Youth in India: Situation and needs
2006– 2007, Policy Brief No. 34. Mumbai: Author.
Jejeebhoy, S.J., S. Kalyanwala, A.J.F. Zavier, R. Kumar, and N. Jha. 2010. Experience seeking
abortion among unmarried young women in Bihar and Jharkhand, India: Delays and
disadvantages. Reproductive Health Matters 18, no. 35: 163– 74.
Kalyanwala, S., A.J.F. Zavier, S.J. Jejeebhoy, and R. Kumar. 2010. Abortion experiences of
unmarried young women in India: Evidence from a facility based study in Bihar and Jharkhand.
International Perspectives on Sexual and Reproductive Health 36, no. 2: 62 – 71.
Ministry of Health and Family Welfare. 2009. Family welfare statistics in India – 2009. New Delhi:
Author.
Office of the Registrar General and Census Commissioner. 2001a. Social and cultural tables: Series
C-8. New Delhi: Author.
Office of the Registrar General and Census Commissioner. 2001b. Primary census abstract: Total
population table: A-5, Series 1. New Delhi: Author.
Planning Commission, India. 2007. Poverty estimates for 2004– 2005. Planning Commission,
Government of India. http://planningcommission.gov.in/news/prmar07.pdf
Solapurkar, M.L., and R.N. Sangam. 1985. Has the MTP Act in India proved beneficial? Journal of
Family Welfare 31, no. 3: 46 – 52.
Sujay, R. 2009. Premarital sexual behaviour amongst unmarried college students of Gujarat, India.
Health and Population Innovation Fellowship Programme Working Paper, No. 9. New Delhi:
Population Council.
Résumé
Alors que plusieurs études ont démontré la prévalence des rapports sexuels pré-maritaux non
protégés parmi les jeunes en Inde, peu de travaux ont exploré l’une des conséquences possibles de
cette prévalence, à savoir les grossesses non désirées et les avortements. Cet article examine les
expériences de 26 jeunes femmes célibataires cherchant à avorter (âgées de 15 à 24 ans) avec
lesquelles des entretiens en profondeur ont été conduits dans le cadre d’une plus large étude, portant
sur des femmes cherchant à avorter dans des centres de soins dirigés par une ONG à Bihar et à
Jarkhand. Les résultats révèlent que la reconnaissance de la grossesse non désirée a été tardive pour
beaucoup d’entre elles, et que pour beaucoup de celles qui suspectaient une grossesse, le temps mis à
la reconnaı̂tre a été encore plus long. Dès la reconnaissance de la grossesse, la majorité des jeunes
femmes se sont confiées à leurs partenaires qui, dans la plupart des cas, leur ont apporté leur soutien;
une minorité significative d’entre elles, comprenant celles qui avaient subi des rapports sexuels
forcés, n’ont pas bénéficié de ce soutien du partenaire, et ont reporté leur avortement jusqu’au
deuxième trimestre de leur grossesse. Le soutien de la famille a été inexistant dans la plupart des cas;
lorsqu’il a été offert, c’était principalement dans le but de préserver la réputation de la famille. Enfin,
plusieurs jeunes femmes ont tenté d’en finir avec leur grossesse, souvent avec l’aide de leur
partenaire ou d’un membre de leur famille, mais sans y réussir. Ces résultats montrent combien il est
nécessaire d’élaborer des programmes ciblant les jeunes femmes et les jeunes hommes, leurs
partenaires potentiels, leurs parents et leur famille, et les système de soins, afin de permettre aux
jeunes femmes célibataires d’avoir recours à des avortements sûrs, dans un environnement où elles
obtiendront de l’aide.
Resumen
Aunque en diferentes estudios se ha documentado la prevalencia de relaciones sexuales sin
protección antes del matrimonio entre jóvenes de la India, se ha analizado poco una de sus probables
consecuencias: los embarazos no deseados y el aborto. En este artı́culo examinamos las experiencias
de 26 mujeres solteras (entre 15 y 24 años) que buscaban servicios de aborto y que fueron
entrevistadas en profundidad en el marco de un estudio más grande con mujeres solteras que
solicitaban abortos en clı́nicas gestionadas por una ONG en Bihar y Jharkhand. Los resultados
indican que muchas mujeres tardaban en darse cuenta del embarazo no deseado, mientras que otras
sospechaban que estaban embarazadas pero tardaban en reconocerlo. Una vez reconocido, la
mayorı́a confiaba en su pareja y normalmente recibı́a su apoyo; sin embargo, una minorı́a
significativa, incluyendo las que habı́an sufrido una relación forzada, no recibieron el apoyo de su
pareja y retrasaron el aborto hasta el segundo trimestre del embarazo. El apoyo de la familia era
ausente en la mayorı́a de los casos, y cuando lo recibı́an, era en gran medida para proteger la
reputación de la familia. Finalmente, varias mujeres jóvenes intentaron sin éxito terminar el
embarazo, a menudo con la ayuda de la pareja o familiares. Los resultados indican que son
necesarios programas para las mujeres y hombres jóvenes, sus posibles parejas, los padres y los
familiares ası́ como el sistema sanitario, lo que permitirá en conjunto que las jóvenes puedan acceder
a abortos seguros en un entorno donde se sientan apoyadas.
Appendix 1
Table A1. Percentages of unmarried women who reported selected abortion experiences by
sociodemographic characteristics (n ¼ 549).
Did not
Delayed recognition receive Did not Made at least
Abortion- of unintended preg- parent/ received one unsuc- Early rec-
related nancy: more than family partner cessful prior ognition,
characteristics two months support1 support1 attempt prompt care
Age *** *** *** ***
15 – 17 38.9 24.2 54.7 28.4 13.7
18 – 19 20.1 47.6 33.0 35.1 18.4
20 – 21 10.1 53.4 16.2 29.7 29.1
22 – 24 5.0 77.7 8.3 35.5 32.2

Education *** *** *** ***
0–4 44.9 18.0 53.9 33.7 5.6
5–7 24.0 24.0 46.0 30.0 16.0
8 – 10 21.2 43.5 34.0 35.4 14.3
11 þ 4.6 73.0 9.9 31.2 36.1
Work status
Working 20.0 58.2 24.3 38.3 21.7
Not work- 16.6 50.0 27.4 31.1 24.0
ing
Residence *** *** *** ***
Rural 44.1 20.2 50.4 31.9 7.6
Urban 10.0 60.5 20.2 32.8 27.9
Experienced *** *** *** *
forced sex
Yes 38.5 18.8 75.0 27.1 13.5
No 12.8 58.7 16.6 33.8 25.6
Notes: *p , ¼ 0.05; **p , ¼ 0.01; ***p , ¼ 0.001.
1
Emotional and financial help as well as by accompanying the respondent to the facility.

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Culture, Health & Sexuality: An

Experiences of unmarried young

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Experiences of unmarried young abortion-seekers in Bihar and

Population Council, New Delhi, India

unintended pregnancy and abortion. This paper examines the experiences of 26

*Corresponding author. Email: skalyanwala@popcouncil.org

ISSN 1369-1058 print/ISSN 1464-5351 online

succeeded in eliciting reliable responses; hence, in order to better understand the

Data and methods

Table 1. Socio-demographic characteristics and abortion-related experiences of unmarried women

Resided 1.5 hours or further from the 25.9 9

relationship, recognition of the pregnancy, communication and decision-making

Recognition of unintended pregnancy

Parental/family reactions and support

Partner reaction and support

underwent abortion in the second trimester:

Unsuccessful previous attempts

Early pregnancy recognition and prompt and appropriate care

22 – 24 5.0 77.7 8.3 35.5 32.2

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