How ASHA Workers Can Help Women Get Abortion

One such woman Dhruv worked with was her 30-year-old client, M. At first, M did not open up to her, Dhruv said. When M was pregnant with her second child, about three years ago, Dhruv helped take her to the hospital for check ups and delivery, as Mitanins do. It was during these hospital visits that M started talking to her about her situation at home.

“During our hospital visits, M started telling me about her husband. He drinks a lot of alcohol, and beats her often. He does not allow her to step outside or take up a job. And he demands sex every day,” said Dhruv.

M was taking contraceptive pills secretly, but her life was chaotic. “Periods main bhi nahi chodta tha. (He wouldn't let her be even during periods.) Or even after delivery of the child,” M told Dhruv.

In this concluding story of our four-part series on abortion in India, we look at the role of ASHA workers--India’s frontline health workers who help improve maternal and child health--in enabling access to abortions.

ASHA workers’ role

The Mitanin Programme that started in 2002 is a precursor to the ASHA programme. ASHA workers have been integral to the public health system in India. Women who work as ASHAs are still considered volunteers and not paid salaries, even as the healthcare needs of the communities they serve increase, IndiaSpend reported in May 2024. They help women during pregnancy, and counsel them to get contraception, both temporary and permanent. Yet, this crucial workforce is barely utilised to help women have better access to abortion.

There is literature published by the National Health Mission including posters and training modules related to abortion for ASHA workers. But, in the four states visited by this reporter--Uttar Pradesh, Delhi, Rajasthan, and Chhattisgarh--the knowledge about the legality of abortion, and abortion facilities varied massively.

In the past few years, Mitanins are getting additional training directed towards helping women and girls seeking abortion, with the inclusion in their training book, Humar Swasthya Humar Haath (our health in our hands). The State Health Resource Centre also has videos to help with awareness (see here and here).

The book Hamar Swasthya, Hamar Haath, a guidebook for Mitanin workers. The page is turned to the part that talks about abortion and post abortion care.

“We realised in our field trips that not much work has been done for increasing access to abortion,” said Anju Gautam, senior programme coordinator at the SHRC in Chhattisgarh. “In our meetings with Mitanins across districts, we realised that most women do not contact their Mitanin didi for seeking abortion. We were not able to capture botched abortions in our maternal death data either.” The SHRC started the Mitanin programme, and was handling it directly. But it was discontinued at the end of last year, and the state unit of the National Health Mission has taken over the Mitanin programme and the ASHA Resource Centre.

This reporter travelled to three districts in Chhattisgarh, in addition to capital city Raipur, to understand how the training and engagement on issues related to abortion assistance may have helped their clients.

Record-taking

As part of their work, Mitanins conduct para baithak or neighbourhood meetings with girls below 18 years and women in separate groups about different aspects related to health of the community. Making them aware about abortion services available in government hospitals is part of that curriculum.

Mitanin workers are supposed to note the records of the relevant medical histories of their community members in a booklet called ‘Mitanin Panji’. This book records the histories of children’s vaccination, of ongoing pregnancies, and contraceptive history, among other details.

Mitanin Panji, a record-keeping book for Mitanin workers. The next photo is the page that records information on pregnant women. One abortion has been recorded in the column “signs of risk pregnancy”.

“We do a panjikaran (writing records) every month where we record the menstrual date of married women every month. During these discussions, a pregnant woman may tell us that their child is too small, and they do not want to continue their pregnancy,” said Dhanai Nitam, who works in Kanker district. If abortion is done and known to the Mitanin, she records it.

All three districts (apart from the capital city of Raipur) visited by this reporter in August 2024 had abortion facilities, and the Mitanins were aware about the kind of abortion facilities that were available. In Kanker, comprehensive abortion services up to 24 weeks of pregnancy are available in the Government Medical College and abortion for first trimester pregnancies was available at community health centres. Most Mitanin workers said that they help about one or two women a year in seeking abortions, but they have heard that many women take abortion pills on their own.

When a Mitanin worker registers pregnancy in the panji or register, there is no separate column to register if the pregnancy is wanted or unwanted. As is clear from the above page in the panji, garbhpat or abortion is registered under the column of “khatre ke lakshan” or signs of high risk pregnancy.

Mitanins in Chhattisgarh make wall-painted posters outside their houses with their names and the kind of services they provide.

“While there is focus in the programme on early registration of the pregnancy, there is less focus on whether the pregnancy is wanted or not. The health system appears to assume that women will continue pregnancy,” said Vikash Keshri, executive director, SHRC in Chhattisgarh.

What happens when community health workers are trained to give both these options?

Action Research and Training for Health (ARTH), a non-profit that works towards improving health, especially reproductive health, of the under-privileged in Udaipur, conducted a long term study between 2007 and 2011. In this study, community health workers including ASHA workers and some selected village health workers, were given training on basics of reproduction, contraception, and abortion, including where to go for abortion.

They were then asked to distribute pregnancy tests to women in the community and follow the flowchart given below to determine if the pregnancy was wanted or unwanted. The training included linking up women with abortion, contraception or infertility services, depending on the needs.

Chart from the paper ‘Taking services to Doorstop’ by Pallavi Gupta, Kirti Iyengar, and Sharad Iyengar, ARTH.

ASHA workers are known as “jaankaar mahila” in Rajasthan, meaning they are smart and knowledgeable, explained Sharad Iyengar, a paediatrician and public health professional, and one of the authors of the paper. He has served on policy and guidance committees with the Union government and Rajasthan government.

“We trained ASHA workers in playing an active role in helping women with unwanted pregnancy,” said Iyengar.

ASHA workers can figure the gestation of the pregnancy, he added. “Depending on gestation, the ASHA workers could decide if the abortion can be done at a health centre (for earlier pregnancy) or to go to a larger hospital for a more advanced pregnancy.”

Poster from National Health Mission on Comprehensive Abortion Care

Credit: National Health Mission IEC material

During the study which included more than 4,000 women, of the 45.1% who tested positive for pregnancy, 39% wanted to discontinue their pregnancy. About 70% of those who underwent abortions went to safe facilities, a high proportion for Rajasthani women, the paper said.

Key informants

In Chhattisgarh, Mitanin workers are posted even in the government health centres to help patients navigate the system. The Mitanin workers at what is called the “help desk” of the hospital are the key informants about the kind of abortion services that are available in the hospital. They serve as the eyes and ears of the public health system in a sense.

Before the Mitanins guide any woman for abortion, they ask the help desk Mitanins if abortion is available, about the behavior of the doctors concerned, and the procedure adopted at the hospital. For example, the help desk Mitanin workers even know if a particular doctor is rude when a woman seeks abortion as she often goes inside wards, and checks on patients.

In the Dhamtari district hospital help desk, Mitanins Arun Sahu and Nirmala Sahu field queries from patients. They direct them to the clinician’s room based on the health issue, and inform patients if a doctor is on leave. They said that abortion is easily available in their hospital, and that they field women’s queries about it every day.

“Women complain that the doctors ask for husband’s consent. We negotiate with the doctors if it's not possible for the woman to talk to her husband about it,” said Arun Sahu. Husband’s consent is not required as per law, but doctors prefer it to avoid social confrontations.

“Women complain that the doctors ask for husband’s consent [for abortion]. We negotiate with the doctors if it's not possible for the woman to talk to her husband about it,” says Mitanin Arun Sahu (right), seen here with colleague Nirmala Sahu.

The knowledge that safe, respectful abortion is available in the Dhamtari public hospital has passed down to community Mitanin workers, possibly creating more demand. “The community may have earlier believed that abortion is illegal or that asking for abortion can cost them. But once the community got to know that it's free of cost here, I am getting more cases,” said Tomeshwar Mali, gynaecologist at Dhamtari district hospital who conducts abortions up to 20 weeks of pregnancy, and admits the patient for a couple days to reduce chances of any complications.

Once the community got to know that abortion is available free of cost, Tomeshwar Mali, gynaecologist at Dhamtari District Hospital started seeing more cases.

It was finally in Dhamtari district hospital that M, the victim of domestic violence mentioned earlier, got her abortion. Mitanin Dhruv negotiated with the doctor herself about doing an abortion without the knowledge of her husband.

“I explained to Sir (the doctor) M’s circumstances at home. Sir told me to sign as a ‘witness’ myself,” said Dhruv. One of M’s more sympathetic relatives also accompanied her. When M’s husband came to hospital demanding that she be discharged, Dhruv convinced him that she had a blood pressure related issue, and warded him off for three days.

Later, after a month, Dhruv arranged for her to undergo sterilisation. M left the discharge card for abortion as well as her sterilisation with her for safekeeping. Dhurv became her keeper of secrets, and helped M negotiate both her complicated personal life and the health system.

Helping underage girls

Mitanin workers talk to adolescent girls about menstruation, menstrual hygiene, good and bad touch, gender-based discrimination, and the freedom to pursue education. There have been some cases where Mitanin workers have intervened in cases of child sexual abuse, including helping to file a police complaint. But for the past two years, the SHRC had decided to expand the scope with adolescent girls.

“We would hear about girls who would get pregnant. We decided to add a section on safe sex and abortion in our curriculum for adolescent girls,” said Gautam.

But the Mitanin workers themselves find it tough to talk to girls about sex and abortion. Mitanins said that they have had complaints from parents that talk about safe sex is akin to “encouraging” the children to be sexually active.

Pushpalata Sahu, Mitanin from Dhamtari explained, “Bahu (daughter-in-law) is like a friend, and beti (daughter) is like my child. We cannot talk to them about condoms.”

That’s why despite the baithaks with adolescents, they do not talk much about issues related to sex, pregnancy or abortion. “I think the girls are too embarrassed to talk about these things,” said Raziya Begum, Mitanin in Kanker district.

Parvati Yadav saw that a 17-year-old in her area was looking pregnant to her.

“The girl did not want to tell me, but I could tell that she is pregnant just by looking at her body and the way she was behaving,” said Yadav, who is a Mitanin trainer in Gariaband district. Identifying a pregnant woman with changes in their bodies is part of their training and experience.

This was in August 2024. “I spoke to her discreetly and told her that we can help her. The parents did not want to speak about her pregnancy as they feared social ostracism. But we assured them that this matter (of pregnancy) would be kept confidential,” said Yadav.

The girl had already had some “medicines” from the jholachap doctor or quack nearby, which had not worked.

Yadav said that when they took her to the Gariaband district hospital, the gynaecologist asked for a sonography report. Some private practitioners they approached refused to conduct a sonography for an underage pregnant girl. In case of abortion with underage girls, the health providers need to inform the police about pregnancy as it attracts the Protection of Children from Sexual Offences Act (POCSO), 2012.

Finally, the Mitanin helped the family find a practitioner who agreed, and discovered that the girl was four-months pregnant. In Gariaband at the time, the district hospital only conducted abortion till 12 weeks of pregnancy.

In the meanwhile, Yadav and her colleagues were still looking for a safe, affordable place which could provide abortion for the adolescent girl by contacting people in her network in the districts and Raipur.

“This girl is from a poor family. We needed to think of a solution for her,” said Yadav.

Eventually, the girl’s family took her to a private practitioner, and got the abortion done, this reporter was informed.

Can ASHA workers help expand the abortion service?

There are more than one million ASHA workers spread across the villages and cities in India. Can they be the crucial link helping support women seeking abortion with the right health facilities?

“Mitanins have an intimate knowledge about the reproductive health of women in their community. While their focus should be family planning and contraception, contraception can fail. A part of this integrated approach to reproductive health should include abortion,” said Keshri.

Abortion leaflet for ASHA workers

The NHM training module covering safe abortion talks about the kinds of abortion (medical and surgical), legalities, post abortion care and post abortion contraception. The Mitanin curriculum additionally talks about helping women deal with abortion stigma and “giving courage” to women and girls to go to the hospital.

Community health workers would be particularly helpful in supporting women post abortion.

“ASHA workers can help alleviate the anxiety of women who may believe that abortion is not complete,” said Iyengar. ASHA workers can help women navigate abortion by informing them about the processes related to abortion, and the time it takes, as well as look for “danger signs” (as described in the figure).

But, it is not clear how much training related to abortion is provided across all states in India, or the extent to which it is absorbed by ASHA workers. In Rajasthan’s Pratapgarh district, ASHA workers IndiaSpend met said that they barely spoke to their clients about abortion, or received any queries about abortion. In Azamgarh, some ASHA workers said that they hesitate to help a woman seeking abortion because they could not take a “risk” of women bleeding excessively.

“We have observed during our interactions with ASHA workers that they don't know enough about abortion,” said Vinoj Manning, CEO of IPAS Development, an international nonprofit that works towards improving access to safe abortion. “Even if they know about abortion, they often do not know where to take women to get an abortion. There is a lack of ability to handle primary questions such as how long it will take for abortion, or what are the symptoms to watch out for.”

As per the National Health Mission at the Central government level, ASHA workers do not get incentives for referring women for abortion. However, some states such as Madhya Pradesh, Assam, Bihar, West Bengal, Uttar Pradesh, Odisha and Karnataka provide incentives starting from Rs 100 to Rs 300. Manning said that not enough ASHA workers know about this incentive, and the uptake is low.

Incentive package for urban ASHAs in West Bengal

“Abortion is such a widespread need, which is being fulfilled mostly by private providers, including chemists and unlicensed abortion providers. It is reasonable to assume that they would have reached out to the local ASHA worker and give her some incentive for getting clients,” said Iyengar. In Delhi, the nonprofit Parivar Seva Sanstha, provides incentives to ASHA workers to get clients for abortion and contraception.

Experts in the field unequivocally said that if such incentives were provided for abortion all over the country, especially at the national level, it will help prioritise safe abortion.

“Having an incentive for abortion referral, even if it's a small one, will help us understand the gaps in understanding of Mitanins, the quality of their counselling, and the uptake of the health service in the community. It will give us a better understanding about the abortion at a systemic level,” said Gautam.

Besides, women in the community are still hesitant to reach out to ASHA workers. Jagriti Baretha, Gariband district coordinator of Mitanin workers, does not find it surprising. She said that it takes time for the community to build trust and change behavior.

“It was a common practice in Chhatisgarh to throw out the first expressed breast milk (colostrum). We worked on this problem for more than a decade, and now we barely hear of such stories. If we work on the abortion issue long enough, women will definitely come forward and seek our help for abortions.” Baretha said.

Series concluded. You can read the first part here, the second part here and the third part here.

This series is supported by the Pulitzer Center.

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