Legal Abortions in the Unmarried Women: Social Issues Revisited

Abstract

Objectives

To analyze the social factors influencing unmarried pregnancies in urban population.

Methodology

Observational study was conducted at the Institute of Obstetrics and Gynaecology, Chennai, from January 2006 to December 2010. Convenience sampling technique was used, and 115 subjects were interviewed using structured questionnaire.

Results

15.6 % of the subjects were <16 years of age, and 40.8 % were between 17 and 19 years. 21.7 % of the subjects were illiterate. In 60 % of cases, the average daily income was less than Rs. 100. There was history of alcoholism in 60 % of family members. 80 % of girls were involved in sexual activity willingly, and in 20 %, the subjects were assaulted by force. Five subjects were mentally retarded. 52 % were involved in sexual activity with married men. 72 % reported for termination in the second trimester.

Conclusion

There is a need for educating girls in the area of gender relationship. Contraceptive awareness should be created.

Introduction

With regard to gender relationship, India is still a conservative country. Because of its strict social, cultural, and religious background, it does not accept premarital relationship and pregnancy outside marriage. Pregnancy in an unmarried woman is always considered a social stigma. However, in recent years with economical freedom, social development, and improved living conditions, there is freedom in gender relationship and the premarital sexual relationship is increasingly being reported which leads to an increase in the incidence of unmarried pregnancy. In a recent survey, 15 % of men and 4 % of women reported of having had premarital sex [1]. There is also cause for concern that sexual abuse is on the rise. According to the report released by the Ministry of Women and Child development, Government of India, 2007, it is estimated that 150 million girls and 73 million boys under 18 have been subjected to forced sexual intercourse or other forms of sexual violence [2]. These premarital sexual encounters lead to unintended pregnancies and because of the tremendous social and financial burden to the individual and the family; these pregnancies are almost always terminated [3, 4].

This study was undertaken to analyze the social factors that have influenced the occurrence of the unmarried pregnancies in our society.

Methodology

This was a hospital-based observational study conducted at the Institute of Obstetrics and Gynaecology, Chennai, from January 2006 to December 2010. During the above period, 1,628 subjects attended the out-patient department requesting termination of pregnancy and among them 129 were unmarried. In this study, convenience sampling technique was used. After counseling and consenting 115 subjects consented to participate in the study. The subjects were interviewed individually by the same observer using structured questionnaire. Throughout the procedure, compassion, privacy, and confidentiality were maintained. In those subjects who were less than 18 years of age, the guardians were also included in the interview. The in-depth interview lasted for approximately 20 min in each individual. The questionnaire included details of demographic variables, social history, occupational history, sexual history, and awareness of contraceptive methods. There were also discrete questions such as who were involved in getting them pregnant, nature of the sexual encounter (consensual or sexual assault), when the pregnancy was recognized and the reason for delay in seeking medical help, and whether previous attempts were made to terminate pregnancy. Data analysis was done using descriptive statistics using numbers, percentage, and mean.

Results

Eighteen subjects (15.6 %) were <16 years of age, 47 (40.8 %) were between the ages of 17 and 19 years, 30 (26 %) were between the ages of 20 and 24 years, 10 (8.7 %) were between 25 and 29 years, and another 10 (8.7 %) were >30 years of age. 111 subjects (96.5 %) were Hindus, and 4 (3.5 %) were Muslims. Analyzing the educational qualification showed that 25 (21.7 %) were illiterate, 27 (23.5 %) had completed primary school education, 54 (46.9 %) were either studying or completed secondary school education, 7 (6 %) were graduates, and 2 (1.7 %) were post graduates. Parental education and their socio-economic status showed that 68 (59.1 %) were uneducated, and 18 (15.6 %) had only primary school education, 23 (20 %) had secondary school education, four were graduates, and two were post graduates. Because of their educational status, 85 of them (73.9 %) were either unemployed or unskilled workers and 30 were (26 %) either semi-skilled or skilled workers. In 69 subjects (60 %), the average daily income was less than Rs. 100/-per day and majority of them were in the below poverty line. 55 Subjects (48 %) were working in export company/leather factories/or as house maids. 60 (52 %) of them were either in school or doing nothing. In the family history, in 69 cases (60 %), there was history of severe alcoholism either in the father or in the brother and in 30 cases (26 %) either or both the parents were not alive (Table 1).

Table 1.

Patient characteristics

	No.	%
Age distribution in years
<16	18	15.6
17−19	47	40.8
20−24	30	26
25−29	10	8.7
>30	10	8.7
Religion
Hindu	111	96.5
Muslim	4	3.5
Educational status
Illiterate	25	21.7
Primary school education	27	23.5
Secondary school education	54	46.9
Graduate	7	6
Postgraduate	2	1.7
Occupation of parents
Unemployed/unskilled	85	73.9
Semi-skilled	30	26.1
Skilled
Family status
Alcoholism	69	60
Parental separation	30	26
None	16	14
Sexual history
Consensual	92	80
Non-consensual	23	20
Pregnancy termination
First trimester	32	28
Second trimester	83	72

In 92 cases (80 %), there was consensual relationship and the subjects were involved in sexual activity willingly. In 23 cases (20 %), the subjects were sexually assaulted by force. Among these, only one case was reported to the police and action was taken. Looking at the persons who were responsible for these pregnancies, relatives were responsible in 32 cases (28 %), neighbors in 36 cases (30 %), people working in the same place in 37 cases (32 %), and classmates in 5 cases (4.3 %). Five subjects were mentally retarded, and the persons responsible for their pregnancies were not known. Among the 23 cases who were sexually assaulted, 13 subjects were under the age of 16 and were subjected to sexual abuse by their own relatives, mostly by their sisters’ husbands. In four cases, neighbors were involved, and in one case, auto driver taking the girl to school was responsible for the pregnancy. The other five subjects were mentally retarded, and the persons responsible for their pregnancy were not known. Analysis of the duration of sexual activity showed that it was unknown in 8 cases (7 %), 1 week in 8 cases (7 %), 1–6 months in 25 cases (22 %), 6 months to 1 year in 28 cases (24 %), and 1–3 years in 46 cases (40 %). Among the 92 cases, who were involved in consensual relationship, 48 of them (52 %) were involved in sexual activity with married men and 34 of them already knew that the male partner was already married.

Analyzing the awareness of contraceptive methods among these 92 subjects who had consensual relationship, it was seen that 80 subjects (86.9 %) were unaware of any contraceptive methods. Though 12 women were aware of contraceptive methods, only in 10 of them the male partners have used condoms. Two women did not know whom to approach for advice. Sixteen women revealed that it is possible for them to marry the same man who was responsible for the pregnancy, yet they wanted the pregnancy to be terminated. The pregnancy was diagnosed in the first trimester in 70 cases (61 %) and in the second trimester in 45 cases (39 %). Though pregnancy was confirmed earlier, only 32 subjects (28 %) reported for termination of pregnancy in the first trimester, while 83 cases (72 %) reported in the second trimester. In these 83 women, the reasons for delay in seeking medical help for termination were analyzed. 35 subjects (42 %) did not recognize pregnancy earlier, 18 feared (21.6 %) going to the hospital, 20 (24 %) of them were scared to tell their parents, 8 (9.6 %) did not know where to go for medical help, and two women (2.4 %) thought that they would marry their male partners. Ten subjects have made prior attempts to terminate the pregnancy with medical methods before reporting to the hospital. Among the 32 subjects who reported in the first trimester, termination was done by medical methods in 10 cases and 22 underwent termination by manual vacuum aspiration. Prostaglandins were used for termination in the 83 subjects who reported in the second trimester. In 82 cases, the procedure was successful, and in one case, hysterotomy was done due to failure of all methods.

Discussion

In a conservative country like India, premarital sex is not accepted, and pregnancy among unmarried women, carries stigma to the individual and their family. There is profound psychological trauma to the affected individual with intense fear and apprehension of being ostracized by the society. However, in recent years, premarital sexual relationships are shown to be on the rise [1]. Currently, there is profound socio-economical development and there is freedom among women to work to maintain their economical status equally with men. When men and women work in the same place as in offices, export companies, leather factories, as house maids, or study together, ample opportunities are created and the environment is conducive for gender relationships. They indulge into sexual act as a matter of chance without understanding the implications of sexual intimacy. In spite of their education, most youngsters lack knowledge about reproductive biology, and the use of contraceptives to prevent unintended pregnancies. Majority of unmarried women seeking abortions are less than 20 years of age. Our study has shown that 65 (56.4 %) of the subjects were less than 20 years of age. Handa et al. [5] also reported that nearly 1/3rd of the unmarried subjects were less than 18 years of age, compared to none belonging to this age in married women. Facility-based studies have found that unmarried abortion seekers are more likely than married abortion seekers to be illiterate or poorly educated and to belong to a lower socio-economic group [5, 6] In Handa et al. [5] study, 32.1 % of the unmarried subjects were illiterate as compared to 19.2 % in the controls. In our study, 21.7 % of the subjects were illiterate. Studies on socio-demographic profile also have shown that 25 % of the unmarried, compared to 16 % of the married, had less than 8 years of education [7]. Lower level of education explains poor knowledge of reproductive biology and the consequences of unprotected coitus. Parental status shows that 73.9 % were either unemployed or unskilled workers with an average daily income of less than Rs. 100/-per day. The above fact indicates that the educational status of the parents and their income play an important role in the occurrence of unwed pregnancies.

In this study, it was interesting to note that there was history of severe alcoholism in 60 % of the family members and in 30 % of cases either the parents were separated or one or both the parents were not alive. It is possible that lack of affection and security in the family can force a girl to seek solace in the opposite sex eventually indulging in sexual activity. Child Abuse Study [2] showed that 10.5 % of children lived with one parent or step parent. Such families being largely dysfunctional increase the vulnerability of children to sexual abuse. Sexual history revealed that in 80 % of cases, there was consensual relationship and were involved in sexual activity willingly and in 20 % of cases, there was sexual abuse/assault by force. The sexual violence is most often inflicted by family members or people who are normally trusted by children. In our study, of the 23 subjects, own relatives, mostly sisters’ husbands, were responsible in 13 cases and neighbors in four cases.

The study on ‘‘Child Abuse’’ has shown that children between the ages of 5–12 are at the highest risk for abuse and exploitation and in 50 % of child abuse cases, the abusers were known to the child and were in a position of trust and responsibility and most children did not report the matter to anyone [2]. Sexual abuse by a family member most often goes unreported. The child is unable to speak about the sexual violence in the home because of fear and the threat by the involved person. Even if the parents know or suspect someone who is sexually abusing a child, they do not know what to do for fear of social stigma and family disruption. In our study, only one case was reported to the police and action was taken, and others maintained secrecy and silence, as the persons involved in the criminal act were most often sisters’ husbands. The above findings show that there is a dire need to protect these helpless preadolescents and adolescents from the hands of their own relatives by educating them to recognize unwanted advances and approaches made by the opposite gender and they should be taught how to avoid them and to report immediately if any such approach is observed. It is disheartening to note that helpless mentally retarded (MR) girls are also sexually assaulted. This is a major issue, and the family and the society should work in harmony to protect these MR girls.

Among the women who were involved in sexual activity willingly, predominantly, relatives, neighbors, and colleagues working in the same place were involved and in most of them the duration of sexual activity was anywhere between 6 months to 3 years. 42 % were involved in sexual activity with married men, and nearly 60 % of them knew that the male partner was already married. Discrete questioning of these women showed that because of poverty their parents could not get them married and the male partners promised them of marriage, gifts, etc. The above finding highlights that poverty is one of the major contributors to unintended pregnancies.

Among the 92 subjects with consensual relationship, except in 2 cases in all the others, as soon as the diagnosis of pregnancy was made the partners refused to provide them emotional support and refused to see them. This finding brings out the important finding of how women are being used and easily exploited by the opposite sex. Most often, married couples seek termination of pregnancy soon after missing the period, whereas unmarried subjects delay a long time till the existence of pregnancy is known to others. Therefore, second-trimester abortions are more common in unmarried subjects. Kalyanwala et al. [8] have shown that 9 % of unmarried women did not realize that they were pregnant until the second trimester. In our study in 39 % of cases, pregnancy was recognized and diagnosed in the second trimester only. Though in 61 % of cases pregnancy was recognized in the first trimester itself, only 28 % reported for termination in the first trimester. Fear of disclosure to partner or parents, delay in decision making, and not knowing where to go for termination were the reasons given by the subjects for delay in seeking abortions early. Pathways to induced-abortion study had shown that being unmarried and experiencing vulnerability by way of lack of support exacerbates the risk of experiencing second-trimester abortion [7]. In Salvi et al. [9] study, 34.9 % presented in the second trimester due to failure to realize that they were pregnant or due to concealment of pregnancy.

Indian adolescents and women are ignorant of birth control and reproductive physiology. Among the subjects who had consensual relationship, nearly 87 % of them were unaware of any contraceptive method and 13/92 did not know whom to approach for contraceptive advice. The above finding emphasizes the need for safe, effective, and accessible contraceptive advice to young women. Similar to our study, other studies have also shown that 85–90 % subjects are unaware of contraceptive methods [6, 10].

Limitation of this study is that it is a hospital-based study where the majority of the subjects are from the lower socio-economic status and the findings of this study cannot be generalized to all abortion seekers.

Conclusion

This study emphasizes the importance of educating the young adolescents on reproductive health and family planning methods. They should be given information and counseling on gender relationship and responsible sexual behavior. They should also be provided with safe, effective, and accessible contraceptive advice so as to prevent these unintended pregnancies. In the event of a pregnancy, they should also have access to confidential and quality abortion services. The unmarried women must be made aware of their rights to obtain legal abortion. As children and young adolescents and mentally retarded girls are vulnerable to sexual abuse, they and their parents should be sensitized to issues of sexual abuse and measures should be taken to protect these vulnerable subjects. It is also important to provide confidential mental health services for those who have experienced any form of sexual violence.