The prevalence and determinants of unsafe abortion were evaluated in the current study in both rural and urban settings in India. It has been demonstrated that women’s age, geographical region, sex composition of the living children, and husband’s level of education are important predisposing and need factors of unsafe abortion in India, both in rural and urban settings. Our findings support the commonsense predisposing factors to unsafe abortion, as concluded by Andersen in the Indian context [7]. However, household wealth status and unmet need for family planning were found to be enabling and need factors of unsafe abortion, particularly in rural India.
In line with prior studies in India [18, 31] and elsewhere [30], the present study found that unsafe abortion was more prevalent in rural than urban areas. A study by Banerjee & Andersen (2012) revealed that women residing in rural areas are often compelled to abort their pregnancies under untrained providers because of inadequate access to safe abortion procedures and a lack of knowledge about the location of safe abortion [7]. In support of these barriers, several prior studies [28, 32] have exhibited the lack of availability of primary health centres (PHCs) along with untrained health care providers in community health centres (CHCs) as the major hindrances to the utilization of safe abortion services in a rural setting. In addition, women in rural settings usually have a lower degree of autonomy and a high unmet need for family planning, which eventually leads them to access unsafe abortion practices [7, 24].
In line with Andersen’s behavioural model, our study also found geographical region as an important predisposing factor of healthcare utilization in the Indian context [7, 29]. Regarding geographical region, the prevalence of unsafe abortion was found to be significantly high in the rural central and eastern regions and may be aggravated due to the existence of socio-economic deprivation and the availability of limited healthcare services [19]. Both high socio-economic poverty and poor maternal healthcare services in rural central and eastern regions negatively affect safe health care service utilization, as suggested by many prior studies [33]. Andersen (1995) also mentioned that regional inequality in terms of the economy, healthcare facilities, and socio-cultural aspects shapes levels of healthcare utilization [29].
We found that early reproductive women had a higher likelihood of unsafe abortion than advanced reproductive women in both rural and urban India, which is consistent with research from Pakistan [34] and Nepal [30] but dissimilar with findings from Ghana [35]. Many previous studies suggested that a lack of knowledge about safe abortion service providers, the legal process of abortion, and the high unmet need for contraception for spacing increased the burden of unsafe abortion among early reproductive women in India and elsewhere [19,20,21, 34,35,36]. Furthermore, the likelihood of unsafe abortion was found to be significantly higher among early reproductive women (15–19 years), particularly in urban settings in India. Therefore, further study is needed to explore why the practice of unsafe abortion is so common among the early reproductive age group in metropolitan India.
There was no significant association between women’s level of education or autonomy and the risk of unsafe abortion practice in India. The result was similar to the previous study in India [19] but dissimilar to the findings from Nepal [30]. Furthermore, the insignificant association between women’s education and autonomy and choice of abortion care indicates that Indian women have limited power to make healthcare decisions. At the same time, the husband’s education was protective in performing induced abortions through unsafe methods in rural settings. The result suggested that all major health care decisions in a household are generally taken by the male member, and improving the level of education increases the utilization of safe health services in rural India [37].
Another interesting finding of our study is that the likelihood of unsafe abortions was found to be higher among women who had only daughters than among those who had only sons. This finding is consistent with several previous studies [18, 38]. The possible explanation for the prevailing variation lies in the practice of sex-selective abortions among women with only daughters, which often remained clandestine and were performed in unsafe settings [39, 40]. However, further study is needed to explore the patterns of unsafe abortion by region with high fertility and low sex ratio to understand better the association between sex-selective abortion or unwanted birth abortions and the risk of unsafe abortion practice.
Among the need factors, the unmet need for family planning was found as a significant determinant of unsafe abortion in India; the result is consistent with prior studies in Ghana [41]. Furthermore, women with an unmet need for family planning are more likely to perform unsafe abortions in rural settings. The unmet need for family planning is positively associated with unintended pregnancy, as suggested by many previous studies [18, 21, 41]. Most unintended pregnancies have been terminated through unsafe methods to minimize the cost of abortion and sidestep the legal procedure of induced abortion in India [24, 42].
In this study, household economic status was found as a function of healthcare decisions in India, particularly in rural settings; the findings support Andersen’s behavioral model. The socio-economically deprived individuals in rural settings mainly sought treatment from untrained healthcare providers [33]. As a result, women from socio-economically disadvantaged groups in rural settings who wanted to have an induced abortion typically sought untrained healthcare professionals.
Policy implications
Our current study’s findings reveal some policy implications. First, an in-depth investigation into the reasons for unsafe abortions in high-focus regions in India is required. Second, safe abortion facilities at the village or ward level are required to ensure service availability and accessibility on the ground level. Third, it could be possible to prevent unsafe abortion by enhancing reproductive health services and reducing unintended pregnancies. Finally, a collaborative negotiation among community-level religious, political, administrative, health representatives and people will be beneficial in spreading fundamental understanding about the updated Medical Termination of Pregnancy Act, 2021, and safe abortion services to the grass-roots level.
Strengths and limitations
The current study has several merits: First, this is the first study to contextualize factors that contribute to unsafe abortion in urban and rural settings. Second, this study systematically examines the similarities and differences between pre-defined factors for healthcare utilization by Andersen and the Indian context. These will be useful for researchers and policymakers to formulate more lenient abortion legislation and healthcare coverage with considering the prevalent risk factors for unsafe abortion in rural and urban India.
Despite having certain advantages, the study also had significant drawbacks. First, the extent of unsafe abortion practices may differ because the data was gathered through self-reporting. Second, the study is restricted to capturing causal relationships between outcome and explanatory variables because of the cross-sectional structure of the data. The current study did not consider other individual-level factors such as self-reluctance to use safe abortion treatments due to stigma, in-law’s disapproval, and societal factors. Finally, selection bias in the study sample may impact the outcomes.