REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200771Quality of Abortion Care: Perspectives of Clients and Providers in JharkhandAlka Barua, Hemant ApteOver the past few decades, there has been growing recog-nition of the importance of the rights of clients in health- care. Indeed, the Programme of Action (POA) of the 1994 International Conference on Population and Development (ICPD) in Cairo highlighted the right of men and women to be informed and to have access to safe, effective, affordable and acceptable health services; in short, a client-centred approach [POA1994]. A key component of the client-centred approach is clearly the qua-lity of healthcare. In India, improving the quality of healthcare is a challenge as efforts are mapped against a background of limi-ted resources, often pitted against the demands of vast health needs. This challenge is even more critical while addressing such sensitive health issues as abortion, where an individual’s privacy, dignity and rights are crucial and legal stipulations are the guiding factor. The few available studies on abortion in India suggest that access to services is poor. Approved abortion services are unevenly distri-buted, with a concentration in the urban areas, and the western and southern regions of the country; in the northern and eastern regions, including the states of Bihar and Jharkhand, availability of services is poor. Quality of abortion care tends to be limited; however, little is known about women’s perspectives of quality of care, particularly in settings where access to services is limited. The objective of this paper is to explore quality of care received by women seeking abortion services in selected settings in Jharkhand, a state in which access to care is limited and evidence about abortion-related care is sparse. The paper explores clients’ perspectives of elements of quality of care, as well as their expe-riences of seeking abortion care and the constraints they face in obtaining services. It also discusses the perceptions of abortion providers on quality of care, and examines the extent to which the perspectives of clients and providers on the quality of abortion care are similar.1 Background and FrameworkIn India, the Medical Termination of Pregnancy MTPAct came into existence in 1972 to provide women access to safe and affor-dable – in other words to “quality”– abortion services. The actgrants women the legal right to terminate an unwanted pregnancy on liberal socio-medical grounds. It permits abortions to be conducted only for specified reasons, by certified medical practi-tioners who are either experienced or trained in gynaecology and obstetrics, and at registered facilities approved by the government to provide abortion. Of the estimated 6.7 million abortions performed annually, only one million are performed at recognised abortion facilities [Khan et al 1999]. Several studies We are grateful to Pertti J Pelto and Leela Visaria for valuable comments. Alka Barua (alki75@hotmail.com) is executive director and Hemant Apte a consultant of Foundation for Research in Health Systems, Ahmedabad. This paper explores the quality of care received bywomen seeking abortion services in Jharkhand, a state in which access is limited and evidence about abortion-related care sparse. It explores clients’ perspectives of the quality of services as well as their experiences of seeking abortion care. It also discusses perceptions of abortion providers on the quality of care.
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly72have noted that large numbers of women obtain safe abortions from uncertified providers or at unregistered facilities; indeed, there are no more than minor differences in the provision of safe abortion between recognised and non-recog-nised facilities [see for example,CEHAT and HealthWatch 2004; Barge et al 1998, 2003; Elul et al 2004; Ganatra 2000; Ganatra and Hirve 2003; Johnston 2002; Ramchandar and Pelto 2004; Visaria et al 2004; World Health Organisation]. The recently concluded Abortion Assess-ment Project notes that abortion is particu-larly inaccessible in rural areas and among socio-economically disadvantaged women [CEHATandHealthWatch 2004]. As discussed earlier, approved facilities tend to be concen-trated in the western and southern regions of the country. Maharashtra, with 10 per cent of India’spopulation,has more than one fifth of the total number of approved facilities in the country compared to Bihar with only 1 per cent of these facilities. Within the states, ap-proved facilities are concentrated in urban areas. The state of Jharkhand, carved out of Bihar, has a large rural population (90 per cent) and amongst the highest rates of induced abortion, maternal mortality and morbidity in India; however, approved facilities in the state offering surgical abortion services are limited [Patel 2005]. Perceptions of Good QualityStudies suggest that women have common perceptions about the components of good quality care including facility-level factors and provider reputation; women also noted cheap services, provider-client interaction that is respectful, confidential and provided by friendly and understanding staff, and the services of a female provider as key components of care. Some women, in addition, perceived the absence of coercion to adopt a method of family planning following the abortion as an important elementof care [CEHAT and HealthWatch 2004; Dhillon et al 2004;Gupte, Bandewar and Pisal 1997]. In some cases, poverty and socio-cultural factors compel women trade-off technical skillsoftheprovider for cheap and confidential services and early discharge. Unmarried adolescents reported low cost of services in addition to provider sensitivity and confidentiality askeycomponents of quality care, leading them to access traditional providers even where safer options are available [Ganatra and Hirve 2003]. Other studies suggest that these qualityofcareconcerns expressed by women are not always met. For example, in Bihar, Gujarat, Maharashtra, Tamil Nadu and Uttar Pradesh, although doctors and other health functionaries conditionally approved of abortion, their interaction with women seeking abortion was not respectful, and many insisted on sterili-sation as a precondition for conducting abortions; in addition, only few women were informed about possible risks or side ef-fects, or post-abortion care [CORT 1995, 1996a, 1996b, 1997a, 1997b; Khan, Barge and Kumar 1998]. Quality of care in govern-ment facilities, similarly, was limited; for ex-ample, one study reports that only 38 per cent of the women who went to public facilities (pri-mary health centre or community health centre) perceived that they got the desired services [Dhillon et al 2004].Studies of providers’ perspectives on qual-ity of abortion care indicate that providers are often unaware of what constitutes quality care. In one study, for example, the majority of auxiliary nurse-midwives(ANMs) were unable to define quality servicesorsuggest how family planning services could be im-proved [Khan, Barge and Philip 1996]. In ad-dition, studies suggest that providers may not feel the need to be responsive to clients’ needs. In Uttar Pradesh, for example, a study reported that many healthworkers believe that poor and illiterate women do not expect counselling or want to make an informed choice; some even question the need for pro-viders to seek clients’preferences,arguing, “Why would women expect good quality care when they get free care?” [Khan, Patel and Gupta 1999].In summary, it is clear that while elements of quality of care are indeed compromised among poor women in India, studies that explore more fully client and provider perspec-tives on the elements of quality of care are sparse.The framework guiding our report is the well known Bruce-Jain framework for measuring quality of care in family planning programmes [Bruce 1990; Jain 1989]. We focus here on the follo-wing elements of quality of care: technical competence or skills and training of the provider; facility-level factors and availability of equipment and supplies; provider-client interaction including confidentiality and level of comfort; pro-vision of information and mechanisms to encourage follow-up; policiesandprocedures; post-abortion care and counselling; and cost. 2 Study Setting, Approach and DataJharkhand one of the country’s least developed states, scoring poorly on health indicators. For example, compared to the na-tionalaverage, Jharkhand has a low level of utilisation of maternal and child health services, with only 24 per cent of mothers of children born during the three years preceding the 1998-99 National Family Health Survey-2 (NFHS-2) having re-ceived three antenatal check-ups (compared to the all-India aver-age of 44 per cent), 18 per cent having had a safe delivery (all-In-dia42percent) and only 8.8 per cent children having re-ceived full immunisation (all-India 42 per cent) [Ghosh and Ladu Singh 2003;IIPS andORC Macro 2000; 2001; Sharma and Sherin Raj 2003]. The state health service delivery systemfaces Table 1: Profile of Women Clients NumberAbortion clients (N=107) Block Urban 33 Rural 36 Tribal 38Age group <30years 59 31-44years 48Marital status Unmarried* 2 Married 105 % married before age 18 56Caste Scheduled caste 10 Scheduledtribe 23 Other backward castes 56 Others 18Education Never attended school 48 Someschooling 59Economic status of the household Lives in pucca house 48 Has toilet facilities 32 Haselectricity 87 Has safe water supply 43 Median number of household goods owned 1Induced abortions 1 94 >1 13* Of these one had an induced abortion before marriage but was married at the time of the interview.the sampling was purposive and non-random, the data were not intended to measure the incidence or prevalence of abortion or preference for providers of a specific category.
As
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly74for providing abortion services, with a well-equipped labour room, operation theatre and indoor services, uncertified private general practitioners and unqualified practitioners generally had a single room with a curtained-off area for conducting abortions. Apart from two private clinics (of a certified medical practitioner and an uncertified general practitioner) in Ranchi, the rest of the clinics visited by the clients were not approved under the MTP Act for the provision of abortion services. Further, not a single uncer-tified private general practitioner accessed by the clients had un-dergone training in providing abortion services, making these abortions technically illegal.4.2 Client and Provider Perceptions of Quality CareClients and providers were asked to list what they perceived to be the components of quality abortion care. Questions focused on what according to them is safe abortion, and what in their view constituted good quality abortion services. Responses were probed in terms of when, where and by whom services were pro-vided, the type of facility accessed and equipment used. The in-terview explored, particularly through responses to service facilities, issues such as privacy, confidentiality, attitude/be-haviour of staff, proximity to home, sex of the provider, effective-ness of the procedure, cost and anything else that theyconsid-ered an integral component of good quality services. Clients and providers were then asked to rank these in the order of importance and to give their reasons. Findings are presented in Table 4.It is clear that seven broad dimensions of quality of care were listed by both clients and providers; what differed markedly was the priority assigned to each and the components of each dimen-sion as articulated by each group.4.3 ClientsAs can be seen from Table 4, several of the elements in our analytic framework, adapted from the Bruce-Jain framework dis-cussed earlier, were indicated as components of quality care. The component of quality of care that was expressed by the largest number of women was cost (78-107). Elements suggestive of technical competence were identified by somewhat fewer: pro-vider competence and skills (68-107) and effective procedure without complications (63-107). Also identified by the many women was the nature of provider-client interaction, including confidentiality/privacy (59-107), availability of a lady doctor (45-107), and friendly behaviour/attitude of staff (42-107). Facility-level indicators were also mentioned such as proximity to resi-dence (50-107) and far less often, availability of requisite equip-ment,appropriate setting, and medicines, round-the-clock services and cleanliness. Narratives clearly suggest that client perceptions of technical competence of providers can differ widely from standard public health requirements. Indeed, formal training, as mandated under the MTP Act, was of little consequence to clients. Rather, as notedby one client: “The doctor should be skilled. He/she should have a good hand at doing abortions” (19 years, rural block, given oral abortfacients by the local chemist). This view was corroborated at a recognised centre in which a paramedic with years of experience of conducting dilatation and evacuation was a more popular service provider than the two trained lady doctors. Technical competence was also defined as one in which the abortion was completed in one visit with no requirement for any follow-up procedures or visits. Indeed, clients were willing to tolerate bleeding, lower abdominal pain, weakness and some discomfort after the procedure but any other complications that required procedural intervention at the facility was, according to them, an indication of poor quality of services. The reason why women go to DrV is because her hospital is close by, within the village, she is a woman, gives good service, is famous and does abortions quickly. There is no waiting time and her treatment is effective. One does not have to go again” (35 years, urban block, visited a gynaecologist’s private clinic). Privacy and ConfidentialityMany women discussed the importance of provider-client inter-action. Although privacy was not a well-understood concept, women clearly perceived the need for confidentiality and secrecy. According to clients, abortions are often sought against the Table 3: Facilities Accessed by Clients for Abortion ServicesFacility ProviderUrbanRuralTribalTotal BlockBlockBlock No of clients 33 36 38 107Private Certified*obstetricians and gynaecologists 13 10 13 36Private Uncertifiedqualified general practitioners 8 8 6 22Government and private Unqualified** providers (including ANM, dai) 11 12 16 39Government primary health centres/Referral hospitals Certified physicians 1 6 3 10*: Certified under the MTP Act to provide abortion services. **: Not qualified or trained to provide abortion services under the MTP Act.Table 4: Indicators of Quality of Abortion Care: Client and Provider PerceptionsClient Perceptions (N=107) Provider Perceptions (N=18)Cost Technical competenceCheap services (N=78) Skilled and trained staff (N=11) Effective procedure without complications (N=5)Technical competence Facility-level factors Skilled and trained staff (N=68) Requisite equipment, facilities (N=9)Effective procedure without complications (N=63) Round-the-clock services (N=4)(N=63) Screening of clients (N=2)Reputation of doctors (N=32) Provider-client interaction Cost Confidentiality/Privacy (N=59) Cheap services (N=10)Early discharge (N=54)Lady doctor (N=45)Friendly, understanding staff (N=42) Facility-level factors Post-abortion care, counselling Proximity to residence (N=50) Counselling (N=3)Requisite equipment/supplies (N=20) Nursing care (N=2)Round-the-clock services (N=19)Cleanliness (N=19) Provision of information Provider-client interactionExplanation of procedure, complications, Confidentiality, privacy (N=4) treatment (N=2) Honesty (N=2) Sensitive, understanding staff (N=3)Policies and procedures PoliciesGovernment recognition of facility (N=5) Liberal MTP Act, relaxation ofAbsence of consent (N=1) rules/regulationsChoice of sex determination (N=1) (N=5)Post-abortion care, counselling Mass awareness campaign for abortion (N=2) services and MTP Act (N=3)
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200775wishes of family members and therefore clandestinely, and as a result, facilities not explicitly identified with abortion services are preferred. Many perceived abortion to be immoral and illegal in India. Under the circumstances, privacy and confidentiality are critical issues with long-term repercussions for clients. As one client explained:According to me confidentiality is the most important aspect because both married and unmarried girls go for abortion. They have not nec-essarily done anything wrong. The girl may go for an abortion because of some compulsions also. I think that when a girl has an abortion and people in the village come to know about it, they think strange things about her and talk ill about her. So if confidentiality is there, her sta-tus/respect in the community would be maintained. People make it difficult for unmarried girls to live in society. People do not hesitate to ruin someone’s reputation or defame her even when she is married. The unmarried are even more vulnerable (22 years, urban block, vis-ited the residence of a nurse for abortion services).Indeed, clients argued for a separate area for abortion clients in facilities, the need to conduct the procedure quickly and to discharge the patient early so as to ensure that family suspicions were not aroused. For the same reason, clients talked about the need for services close to home; only three clients preferred to avail of abortion services at a distance from their homes. Almost a third of the women (45-107) mentioned the need for a lady service provider. Not only did women indicate feelings of “sharam” (embarrassment) in the presence of a male doctor but also argued that a woman doctor was in a better position to un-derstand the “duvidha” (dilemma) of aborting a foetus and to dis-cuss these dilemmas with clients and to counsel them. As one client said, “If there is a lady doctor, there is guarantee of less pain and problems. A lady doctor is necessary because women can talk openly without any embarrassment or hesitation” (33 years, urban block, visited a gynaecologist’s private clinic). Another client similarly noted, “If the doctor is female there is no embarrassment….the woman can talk to her openly” (19 years, rural block, given oral abortificients by the local chemist). In the same context, women stressed that understanding, friendly and non-judgmental behaviour of staff at the facility was essential. Requisite equipment and clean facilities, availability of medicines and round-the-clock services were ranked lower as key indicators of good quality abortion services. Of note is the finding that provision of information about the procedure, gov-ernment recognition of the facility and the absence of require-ments of husband’s consent were not considered to be as impor-tant. Interestingly, one educated woman with a son mentioned availability of facilities for sex determination as an indicator of good quality abortion care, suggesting perhaps a familiarity with this practice even in rural and tribal Jharkhand. As she noted, “Facility for foetal sex determination should be available. This is a good test; it meets people’s needs and prevents the birth of an unwanted child” (36 years, tribal block, referred by a private gynaecologist in Ranchi to a private clinic in Bilaspur, Madhya Pradesh for sex determination, before terminating the pregnancy).Across the three blocks, there were differences in the way quality of care was perceived, which was a direct reflection of the location of the site. For example, in the tribal block, which is at a distance from the state capital, more women, as compared to women in the other two blocks, mentioned the need for trained lady doctors closer to home. This was also the block where there was greater stress on the availability of requisite equip-ment andclean facilities that offer services round-the-clock. On other indicators of quality all the three blocks presented a similar picture.4.4 ProvidersAs can be seen from Table 4, quality of care as identified by pro-viders is quite different from that identified by clients. Of the 18 service providers interviewed, half or more mentioned skilled and trained staff (11-18), requisite equipment and facilities (9/18) and cheap services (10-18) as essential components of good quality care. Providers, particularly those from government centres, were categorical that of all indicators, skilled and trained staff was the most critical, but not sufficient; the importance of equipment and facilities were also noted and highly ranked. Such factors as counselling, confidentiality and round-the-clock services were ranked lower as indicators of quality. Indeed, sensitivity and compassion towards the client featured very low in importance, though three providers mentioned it. As one dai said: “the provider should have keen eyesight, a clean hand and if he/she is caring in the bargain, then that is an added advantage”. Likewise, only two providers identified contraception-related counselling as an essential element of quality of abortion care; in their opinion, a measure that prevents repeatofpo-tentially harmful activity is the hallmark of good quality of service rendered. Two unqualified providers talked about the need for provider honesty and trustworthiness as prere-quisites for quality service provision. Two gynaecologists, who have a private practice, noted the importance of thor-oughly screening patients and providing proper nursing care after the procedure. Several providers discussed the importance of easy access to services as a measure of quality. Some providers (5-18) argued that the requirements of theMTP Act themselves posed a limita-tion on easy access to services; these providers argued that qual-ity and access would be enhanced if abortion services are de-regulated and a larger number of abortion service centres and providers are legally recognised. In their view, the stringent regulations for registration are a major hindrance to the provision of good quality and safe abortion services, thus defeating the very purpose for which the MTP Act came into existence. As a trained and certified physician employed in a government facility argued: All that ensures the provision of “safe abortion” constitutes good quality care. The components may not remain static….Under certain circumstances it could be infrastructure, under others it could be patient satisfaction. Suppose a client wants to terminate the preg-nancy and the provision under the [MTP] Act does not allow it, do I send her away? Such acts are unsustainable and send women to unqualified providers thus compromising on quality. What use is an excellent infrastructure if it does not meet the requirements of the client? In a similar vein, a few providers (two certified and one uncer-tified) also noted that access to quality services was impeded by 
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly76lack of community awareness about safe practices and providers. They noted the need to raise awareness levels of safe abortion practices and their locations, even arguing for a mass awareness campaign about the MTPAct and available services as strategies for enhancing quality care.4.5 Client Experiences of Quality of Abortion Services Our study explored the experiences of clients, including factors influencing choice of provider and assessments of quality of services rendered. By and large, women preferred to obtain abor-tions from private rather than government health facilities, which were perceived as a last resort facility if other efforts failed or other providers refused to undertake the abortion. In addition, home use of medical abortion, purchased from chemists, was observed.Our study also examined the factors influencing women’s choice of provider and assessments of quality of services rendered. Questions focused on facility-level factors such as availability of medicines and indoor services, proximity, convenience; technical competence of the provider including reputation, training and skills; provider-client interaction in-cluding maintaining privacy and confidentiality, sex of the provider, attitude and behaviour of staff; effectiveness of treatment, absence of side-effects or complications, follow-up services and affordability. Women were asked to name the most important of these components that determined their choice of provider.Our findings suggest a general consistency between per-ceptions of quality of care reported in the section above and women’s own experiences. As can be seen from Table 5, provid-er-client interaction, and specifically, such elements as confi-dentiality and privacy, inter-action with staff members and sex of provider appear to have been reportedbyalmost allwomen; indeed, substan-tially more than those dis-cussing technical skills of providers and facility-level factors, convenience and cost in the choice of provider. Unqualified practitioners were preferred because with a single exception they were female, maintained confidentiality, were located close to the houseof the client, and their services were affordable and avail-able round-the-clock thus being convenient for clients. Clients who had accessed services of certified private medical practition-ers claimed that they preferred these providers because they were reputed, trained and experienced, behaved well, offered explanations for the care provided, and had well-equipped and convenient facilities. While clients said that the government facilities were affordable, recognised and the providers were trained, they noted that as the same providers offered their services through their private clinics, they preferred to access their services privately as these facilities were better equipped, available round-the-clock and confidentiality and secrecy could be ensured. There were differences in the three blocks in the importance given by clients to the various dimensions of quality of care. More women in the tribal block mentioned confidentiality (20-38), cost (18-38) and presence of a female service provider (13-38) as rea-sons for choosing a specific provider, as compared to women in the other two blocks. This was also the block where more women clients of unqualified practitioners were interviewed as com-pared to the other two blocks. Though a similar number of wom-en clients of certified private medical practitioners and uncerti-fied private general practitioners were interviewed from both the urban and tribal blocks, more women from the urban block men-tioned reputation and behaviour of the service provider as rea-sons for opting for his/her services. On the other dimensions of care, the three blocks were not significantly different.4.6 Provider-ClientInteraction The vast majority of women reported that the quality of provider-client interaction was a key factor determining their choice of provider. Indeed, privacy and confidentiality were among the foremost criteria (98-107) for choosing a provider. Correspond-ingly, in several narratives, women identifiedlackofprivacy and confidentiality as reasons for their dissatisfaction with serv-ices. For example:There was only one room divided into two by a curtain. In one part, the doctor examines patients and in the other, abortions are carried out. There is no separate operation room. Anyone passing by can see everything happening there. Confidentiality was completely lacking. This was rather disturbing. I would not advise other women to get an abortion done by this doctor because there is no privacy (35 years, ur-ban block, visited an uncertified private general practitioner’s clinic).A similar view was expressed by a much younger client:Where I went for the abortion, there was no privacy. Everyone came to know about it. In future, if I have to go I would go to some other reputed/established doctor even if he is far away from home. That way nobody would come to know about it. Doctors in Kanke and Ranchi are experts, reputed, perform a safe abortion and also maintain confidentiality (19 years, urban block, visited an unqualified private practitioner’s clinic).This view was endorsed by the medical officer at a primary health centre, who claimed that lack of privacy at the centre was responsible for the small number of abortion clients who seek care there. Despite two trained lady medical officers and neces-sary equipment, the primary health centre conducted no more than one or two abortions per month; and in fact, these tended to be women who were refused services byANMs or private doctors, or who had unsuccessfully tried “over-the-counter” drugs obtained from chemists, or those undergoing a repeat abortion within six months. That the lack of privacy and confidentiality at the primary health centre made it the last resort for women turned away from other facilities resulted, obviously, in clients delaying abortion till the end of the first trimester or beginning of the second trimester. The medical officer also noted that the posters displayed in the primary health centre – one stating the availability of abortion services at the centre and the Table 5: Factors Influencing Women’s Choice of ProviderClients’ Experiences (N=107) NumberProvider-client interaction Confidentiality/privacy 98 Ladyprovider 96 Good behaviour/attitude of staff 94Technical competence Reputation of staff 68 Experience/skills of staff 32Facility level concerns* 65Convenience/proximity/early discharge 54Availability of medicines 40Availability of staff 40Cost 63*Round-the-clock services, short waiting time, availability of supplies and equipment.
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200777other titled “Garbhpaat ke baad Garbh Nirodh” (contraception after induced abortion) – appeared to inhibit rather than attract abortion seekers as she believed that they feared that advertis-ing the availability of abortion facilities would compromise their confidentiality.In the rural block, medical abortion (mifepristone and miso-prostol) is becoming increasingly available not only through medical facilities and providers but also over-the-counter by chemists. Despite the fact that it is illegal, some women report the experience of medical abortion with medication obtained from chemists. Again, clients appeared to prefer medical abortion for the privacy and confidentiality it afforded them. According to one client:At the chemist’s shop there is a separate room for these activities. I am satisfied with the services. Secrecy was maintained and the place was not crowded. I would go there again if there is a need. I would also recommend this place to others (28 years, rural block, given oral abortifacients by the local chemist).Closely linked to issues of privacy and confidentiality is the quality of interaction with providers. For one, most clients reported that the sex of the provider was important in enabling interaction with the provider. A large number of study parti-cipants (96/107) reported that they would not be as comfortable interacting with a male provider as with a female, and hence had deliberately selected a female provider. The extent to which providers are respectful of clients and make efforts to ensure client comfort and confidentiality was also cited as a critical element in the choice of provider. Most clients (94-107) reported that they placed high value on providers who pay attention to their concerns, are friendly, communicative, caring and sympathetic, assure them of safety and confidentiality, and provide them punctual services, and deliberately sought providers who met these criteria. Many clients reported that private facilities were more likely to pro-vide this kind of interaction than were public health facilities. For example, “Abortions should never be done in government or NGO hospitals. They should be done in private hospitals as there is privacy and the staff is intelligent and prudent” (32 years, urban block, visited a certified private medical prac-titioner’s approved facility).Another client from a rural block lamented, “I would never go [to the government hospital] ever again. I would never advise anyone else to go there. The staff, including the nurse, behaves very badly. If a woman screams, the nurse threatens to tie her hands and legs” (25 years, rural block, visited a gov-ernment facility).Yet another client expressed disappointment:I am not happy with this doctor [from the government hospital]. I was not asked to come back after the abortion. Even if I had been called I would not have gone. The staff does not tell us anything. They immediately give the client an injection, make her unconscious, con-duct the abortion and send her home while she is still unconscious. That is the reason I will never go there. If there is really a need I would go to another clinic (25 years, urban block, visited a govern-ment facility).In contrast, women reported satisfaction with services in which interaction with the provider was perceived positively, even if, as the following narrative suggests, the provider did not spend much time with the client: “The behaviour of the doctor and nurse was very good. The doctor was very brief” (27 years, tribal block, visited an unqualified private provider).The following words of a client also reveals satisfaction:There was no problem during the abortion. The doctor gave me some tonic. The behaviour of the doctor and nurse towards me was good. There was a brief discussion between the doctor and the nurse. But they told me nothing . ...I do not think that this is required because the doctor knows best about what is right and wrong for me. Whatever the doctor does will be for my benefit (30 years, tribal block, visited an uncertified private provider).Lack of KnowledgeFinally, while not identified by women as an indicator of quality, it is clear from narratives that although women were by and large unaware about “safe” or “legal” abortion or the right to information, providers did not deem it necessary to share information with clients and clients rarely sought or expected information. Narratives suggest that women were rarely in-formed about alternative methods of abortion or possible complications; nor were they counselled about post-abortion contraception. For example:I reached there at 2.30 p m and everything was over by 3 o’clock. At 3.15 I was home. No advice was given and because I felt quite ashamed, I did not ask anything. I felt that everything should be done quickly and I should get out of the room at the earliest. I was not interested in knowing about methods of abortion and so on. I only wanted to know how much it would cost. No special method [of contraception] was suggested to me. Nor was I asked to choose a particular method (22 years, urban block, visitedthe residence-cum-clinic of a nurse).In a few cases (3), this lack of knowledge had adverse but pre-ventable consequences:When I went for an abortion, there was no discussion, no conditions were laid down and no advice was given. They did not tell me anything about other methods of abortion. Nobody told me anything about any complications. I had the same problems that are generally there after abortion. There was a lot of bleeding. I thought that it would subse-quently reduce on its own. But for eight days I was bleeding. I could not get up (25 years, urban block, visited a government certified physi-cian in a primary health centre). 4.7 Technical Skills and Training of ProvidersWhile the factors discussed above were prime considerations, women were also concerned about the provider’s reputation (68-107) while choosing a particular provider. Narratives of their experiences corroborate the importance of perceived provider skills. Many reported that despite higher fees and the need to travel longer distances, they had sought care from pro-viderswhose skills were well known or who were reported to conduct safe abortions with no complications. There is a sug-gestion, however, that women may be equating high costs with better quality:To me the most important thing is the guarantee that there will be no problems during and after the abortion. I am ready to compromise on the cost of services and the rude behaviour of the provider but there should not be any problems. I have learnt this from my own experi-ence (25 years, urban block, visited a dai).
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly78While many spoke generally of seeking services from a repu-table provider, some women (32-107) specifically mentioned that training and skills of providers were critical determinants of their choice of provider, arguing for a formally trained provider, with a definite preference for gynaecologists: I would not advise other women to get an abortion done by the regis-tered medical practitioner[RMP] because …he is not a gynaecologist. I would advise others to go to Dr U or Dr S because they are special-ists, they do safe abortions... it costs more …but the most important thing is that they are gynaecologists (19 years, urban block, visited an unqualified private practitioner’s clinic).We note however that most women focused not on the formal training or qualifications of the provider but her/his reputation for competence. Although this view was most likely to be ex-pressed by women in the remote tribal block (over half of all women interviewed), women from other blocks also shared this view. For example:While the staff at S clinic [an abortion clinic] is good compared to other abortion facilities, I am not happy with the treatment given. My experience was contrary to my expectations. I had health problems following the procedure. I think this is because the doctors are not experienced. They are trained but fresh doctors. Experienced doc-tors do the abortions properly… it is important to have a skilled and experienced doctor…By experienced I mean that the pro-vidershould have performed many such procedures earlier and should be skilful (32 years, urban block, visited a certified private medical practitioner).Indeed, some medical professionals also tended to agree with this view. In the urban block, the medical officer noted that the medical officers at the primary health centre refer difficult abortion cases to the ANM, who is old and skilled but cannot read or write, rather than to trained gynaecologists. According to the ANM, her expertise is the result of practice and lack of fear, “when you cook vegetables everyday you do not make mistakes but if you do it once or twice in a month, the proportion of ingre-dients may go haywire” (ANM, block primary health centre, urban block).4.8 Facility-levelConcernsA large number of narratives (65-107) suggest that facility-level concerns played a role in determining women’s choice of abortion provider. Important among these concerns were such issues as proximity of the facility, round-the-clock services, short waiting time and availability of supplies and equipment.Since the majority of respondents were married, with small children and living in joint families, the need for flexible timings was critical as few women reported the ability to seek services at timings that interfered with their daily household choresandresponsibilities. For similar reasons, several women (54-107) reported going to doctors whose clinics were close to their residence, “I generally take treatment from Dr K who is much better than the other doctors. Though she is costly and thebehaviour of her staff is not good…. I go there because it is close to home….The place should be close to home” (32 years, urbanblock, talking about a certified medical practitioner’s private clinic).Another woman stated:I chose this hospital because it is open 24 hours of the day. It is fully equipped with a laboratory, X-ray room, etc. Medicines and injections are available in the hospital itself. Doctors are available even at night. Otherwise one has to spend on transport to go back again or gotoanotherplace(30years,tribal block, visited a certified private gynaecologist).Long distances to abortion facilities were most likely to be re-ported by clients from the remote tribal block, who were therefore most likely to argue for abortion facilities located in every village: In addition to the availability of a skilled lady gynaecologist, the other important criterion is proximity of the hospital to home as distance makes transportation difficult, expensive and time-consuming. The hospital should be near the home/village so that everyone can access it easily (30 years, tribal block, used the services of a private gynae-cologist in Ranchi).Proximity to the home was preferred by most women, “The hospital should be located close to home. Abortion facilities should be available at every village” (28 years, urban block, used the services of a local nurse). Indeed, while most womenpre-ferred a facility located close to home, for some women (3-107) the issue of confidentiality over-rode concerns about proximity of the facility. “I went to Dr H because not only is she an expert in abortion, but no one comes to know abouttheabor-tion as her clinic is far from my village” (33 years, urban block, visited a gynaecologist’s private clinic).Aside from issues of distance and flexible timings, women also noted that access to a clinic and trained manpower were mean-ingless unless staff, equipment and medicines were also available and waiting time was limited. Indeed, 40 of 107 women specifi-cally mentioned that availability of staff and medicines were critical in their choice of provider. Correspondingly, several women who obtained abortions from government facilities re-ported their dissatisfaction with the quality of care received. For example, they noted that their families were asked to purchase medicines from outside, a practice that women found not only inconvenient but also affected both cost and confidentiality, “A woman should get the service when she wants it. I had to spend a whole day from 9 in the morning till 3 in the afternoon for the nurse to conduct the abortion. I found it very long” (29 years, tribal block, visited a private unquali-fied provider).The availability of medicines was of concern, “I have no com-plaint about the services I received. The experience was good. But the doctor did not have the medicines. My husband had to go frequently to the shop to buy medicines or other things that were needed. It was rather inconvenient” (26 years, urban block, visited a gynaecologist’s private clinic).Facility-level issues were most strongly voiced by women from the tribal block in which round-the-clock services were not available and referral facilities were either poorly equipped or serviced by trained medical officers for no more thana couple of hours in the morning, a time inconvenient to most women. In contrast, in the rural block inwhich clients tended to exercise the option of medical abortion, and in the urban 
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200779block in which women had relatively easy access to facilities inthestatecapital,Ranchi, clients were less likely to focus on the need for 24-hour facilities.4.9 CostAnother factor influencing choice of provider was cost, reported by over half the clients (63/107). While cost of services did not prevent women from undergoing an abortion, it did determine the choice of facility. As a result, women who could not afford fees charged by private qualified providers sought care from government or unqualified providers. At the same time, women clearly linked cost with quality, “I had to spend more money. But one has to spend more money for treatment at private [facili-ties]. If you want all the facilities you have to spend money” (30 years, rural block, visited an uncertified private general practitioner’s clinic).Likewise, women for whom cost was a concern tended to seek care from those perceived to provide cheaper services, even when they had concerns about the provider’s technical skills. Forexample, “I did not go to the hospital because we are poor and hospitals charge a lot of money. I therefore preferred to go to the nurse [ANM] who conducted the abortion for lesser fees. Thosewhohave more money should go to hospitals since these have all the facilities”. (25 years, tribal block, visited a nurse who prescribedtablets).The cost factor was expressed by yet another client:Our local doctor is not a gynaecologist, or even a qualified doctor. He can treat cough and cold. We are compelled to take treatment from him because we do not have much money and he lives close by. If, after his treatment, we still have problems, then at the last stage we go to Kanke or Ranchi (19 years, urban block, visited anunqualified practi-tioner in a private clinic).Narratives suggest that while in general, cost was less likely to be reported as the leading criterion underlying the choice of a provider, in the tribal block, it was a key factor; women were unanimous about the need for free, cheap or subsidised medi-cines, and free services. 5 MovingAheadOur study probed the perceptions and experiences of women seeking abortion services in a resource-poor state of India in which safe abortion services are limited. Findings suggest that while both clients and providers perceive a similar set of ele-ments in their definitions of quality, the priority placed on indi-vidual elements vary considerably. While providers rank techni-cal skills above all, clients give relatively more priority to such concerns as confidentiality, provider attitudes, cost and facility-level issues.Sensitivity to Women’s Issues Women’s own decision-making and experiences largely reflect these perceptions in choice of provider in all three settings. It is clear that issues relating to client-provider interaction are para-mount in women’s perceptions of quality (ranking third, see Table 4, p 74) and in the choice of provider (ranking first, see Table 5, p 76). Indeed, confidentiality and privacy over-ride all others in women choice of an abortion provider, and government health facilities are largely avoided because of their insensitivity to these issues. It is interesting to note that medical abortion is appreciated by women not so much because of its non-surgical features but because confidentiality can be better assured with medical than surgical abortion. Also of concern to women – but somewhat less important than quality of provider-client interaction – are such factors as techni-cal skills and training of providers, affordability of services and such facility-level issues as distance, timings, waiting time and availability of supplies and equipment. It is interesting to note that while women perceive cost to be a leading indicator of quality, it appears to have played a somewhat less important role than other factors while choosing a provider. Likewise, while technical skills of the provider are highly ranked indicators of quality, they rank somewhat lower than quality of interaction in determining choice of provider. Finally, just as neither providers nor clients identified the need for information as an important aspect of quality, not a single client referred to provision of infor-mation or absence of spousal consent as key in choice of provider (although it may be implied more generally under quality of pro-vider-client interaction). Inadequacies of MTP ActOur findings suggest that the unambiguous stipulations of the MTP Act to ensure provider skills and physical standards of the facility, while obviously necessary, are far from sufficient in at-tracting clients to certified providers and recognised facilities. Equally important (if not more important) are other standards of quality – notably confidentiality, respectful interpersonal provider-client relations, and the presence of a female pro-vider. It is of some concern therefore that few providers con-sider provider-client interaction as key in their conceptuali-sation of quality.We note, moreover, that while affordability was a leading fac-tor in women’s conceptualisation of quality, it was described as a key factor underlying choice of provider only among women in the tribal block; indeed, it appears that quality of provider-client interaction is so important that women are more willing to incur significant costs in obtaining abortion services than undergo abortion at government facilities. Our findings suggest that in the current health service delivery scenario in Jharkhand, women face many obstacles in accessing quality abortion services in the public sector. Not only are the re-quirements noted in the Act – technical skills and availability of well-equipped facilities – unmet, but also factors deemed key by clients are unavailable. As a result, private sector providers are generally preferred and quality services therefore obtained at a cost that few can easily meet. Narratives of abortion-seekers highlight the need to address not only technical compe-tenceofproviders and quality of facilities but also the more central issue of availability of female providers, confiden-tiality and respect for clients in order to make services acceptable to clients.If this is to be achieved, given field-level realities, there is a need to review the stringent recognition criteria of the Act to focus 
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly80on “safe” rather than certified providers, to train and enable para-medic female staff to provide services and to enable greater access to affordable medical abortion to rural women inJharkhand. These factors would go a long way in increasing the accept-ability of public sector services as a legitimate first option rather than a last resort. 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