Evaluation of a multi-pronged intervention to improve access to safe abortion care in two districts in Jharkhand

BACKGROUND: Despite the adoption of the Medical Termination of Pregnancy Act in 1972, access to safe abortion services remains limited in India. Awareness of the legality of abortion also remains low, leading many women to seek services outside the health system. Medical abortion (MA) is an option that has the potential to expand access to safe abortion services. A multi-pronged intervention covering a population of 161,000 in 253 villages in the Silli and Khunti blocks of Jharkhand was conducted between 2007 and 2009, seeking to improve medical abortion services and create awareness at the community level by providing information through community intermediaries and creating an enabling environment through a behavior change communication campaign. The study evaluates the changes in knowledge about abortion-related issues, changes in abortion care-seeking, and service utilization as a result of this intervention. METHODS: A baseline cross-sectional survey was conducted pre-intervention (n = 1,253) followed by an endline survey (n = 1,290) one year after the completion of the intervention phase. In addition, monitoring data from intervention facilities was collected monthly over the study period. RESULTS: Nearly 85% of respondents reported being exposed to safe abortion messaging as a result of the intervention. Awareness of the legality of abortion increased significantly from 19.7% to 57.6% for women, as did awareness of the specific conditions for which abortion is allowed. Results were similar for men. There was also a significant increase in the proportion of men and women who knew of a legal and safe provider and place from where abortion services could be obtained. Multivariate analysis showed positive associations between exposure to any component of the intervention and increased knowledge about legality and gestational age limits, however only interpersonal communication was associated with a significant increase in knowledge of where to obtain safe services (OR 4.8, SE 0.67). Utilization of safe abortion services, and in particular MA, increased at all intervention sites over the duration of the intervention with a shift towards women seeking care earlier in pregnancy. CONCLUSION: The evaluation demonstrates the success of the intervention and its potential for replication in similar contexts within India.