RAJIV GANDHI UNVERSITY OF HELATH SCIENCE,
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / : / NINGTHOUJAM PRAMODINI DEVI1ST YEAR M.SC NURSING,
INDIAN COLLEGE OF NURSING, TILAK NAGAR, BYPASS ROAD, CANTONMENT,
BELLARY – 583104
2. / NAME OF THE INSTITUTION / : / INDIAN COLLEGE OF NURSING, TILAKNAGAR, BYPASS ROAD, CANTONMENT,
BELLARY – 583104
3. / COURSE OF STUDY AND SUBJECT / : / DEGREE OF MASTER OF NURSING ,
OBSTETRICS AND GYNAECOLOGICAL NURSING
4. / DATE OF ADMISSION TO COURSE / : / 17-05-2010
5. / TITLE OF THE TOPIC
/ : / A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING ABORTION AND ITS MANAGEMENT AMONG STAFF NURSES IN SELECTED HOSPITALS, AT BELLARY, KARNATAKA.
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION:
“Abortion is the ultimate exploitation of women”
Black terms abortion as “knowing destruction or intentional removal”.1 Abortion is the termination of pregnancy before the fetus becomes viable. Viability is usually reached at 28 weeks when the fetus weights slightly more than 1000g (WHO).2 Hippocratic physicians in Ancient Greece forbade doctors from helping to procure an abortion by pessary. Soranus suggested in his work Gynaecology that woman wishing to abort their pregnancies should engage energetic exercise, energetic jumping, carrying heavy objects and riding animals or by various methods including herbal abortificients, the use of sharpened tools, physical trauma.3
Abortion is the most common serious complication of pregnancy and it is not notifiable, and difficult to get the accurate incidence. In general, the incidence varies from 10-15 %. Abortion, in its most common usage, refers to the voluntary, or induced, termination of pregnancy. Pregnancy is the process by which a mammalian female carries a live offspring from conception until it develops to the point where the offspring is capable of living outside the womb.
It starts with conception, the process of fertilization to form a zygote, and ends in newborn, miscarriage, or abortion. In human, pregnancy takes approximately 40 weeks between the time of last menstrual cycle and delivery (38 weeks from fertilization). It is divided into three trimesters. The first trimester carries the highest risk of miscarriage, the unintentional abortion of a fetus.
Medically, the term also refers to early termination of a pregnancy by natural causes (“spontaneous abortion” or miscarriage). Miscarriage is the term for the natural or accidental termination of a pregnancy at a stage where the fetus is incapable of surviving. The medical term for it is “abortion” when the abortion is not deliberately induction, it is termed a “spontaneous abortion” so that is a synonym for miscarriage. Miscarriage can occur for many reasons, not all of which can be identified. While miscarriage can result from physical trauma life exposure to certain chemicals, diseases, or physical blows. A miscarriage usually results from biological defects in the developing fetus.4
As per India’s abortion laws only qualified doctors, under stipulated conditions, can perform abortion on a woman in an approved clinic or hospital. Medical Termination of Pregnancy (MTP) Act, which was enacted by the Indian Parliament in the year 1971. The MTP Act came into effect from April 1, 1972 and was once amended in 1975. Mifepristone with misoprostol is favorable if pregnancy is 7 weeks. Vacuum Aspiration (suction evacuation) is
the most commonly-used method for termination of early pregnancies. Surgical abortion is preferred if patient desires concurrent tubal ligation. However, being a surgical technique, it is associated with risk of infection, incomplete abortion. 5
6.1 NEED FOR STUDY:
Vaginal bleeding in the first trimester is a common complication of pregnancy.6 Abortion constitutes a major cause of maternal mortality and mortality of South East Asian Countries. The selective abortion of female fetuses is most common in areas where cultural norms value male children over female children especially in parts of People’s Republic of China, Korea, Taiwan and India.7 The prevalence of legal abortion varies widely across the countries in which it is generally available. Where the abortion rate is high, it likely reflects that levels of contraceptives use are not sufficient to meet the fertility desires and family planning needs of women and couples.8
The world wide incidence is estimated to be 42 million cases of abortions. Annually with 22 million of these occurring safely and 20 million unsafely. While maternal mortality seldom results from safe abortions, unsafe and safe abortions result in 70,000 deaths and 5 million disabilities per year. 9 When legally performed abortion in developed countries the maternal death is
between 0.2- 1.2 per 100.000 and for unsafe procedures, the mortality rate has been estimated at 367 per 100,000 (70000 women per year world wide).10 complications of unsafe abortions are said to account, globally, for approximately 13% of all maternal mortalities, with regional estimates including 12 % in Asia, 25% in Latin America & 13% in Sub-Saharan Africa. Although the global rate of abortions declined from 45.6 million in 1995 to 41.6 million in 2003, unsafe procedures still accounted for 48% of all abortions performed in 2003.11
An International Family Planning Perspectives was conducted on legal abortion worldwide. Statistical legal abortion in 2003 was compiled for 60 countries in which the procedure is broadly legal and trends were assessed. Data sources included published and unpublished reports from official national reporting systems, questionnaires sent to government agencies and nationally representative population surveys. In recent years, more countries experienced a decline in legal abortions rates than an increased. The most dramatic declines were in Eastern Europe and Central Asia, where rates remained among the highest in the world. The highest estimated levels were in Armenia, Azerbaijam and Georgia. The US abortion rate dropped by 8% between 1996-2003, but remained higher than rates in many Northern and Western Europe countries. Rates increased in the Netherlands and New Zealand. The official
abortion rate declined by 21% over seven years in China, which accounted for a third of the world’s legal abortions in 1996.12
Accordingly to the Consortium on National Consensus for medical abortion in India. Every year an average of about 11 million abortions take place annually and around 20000 women die every year due to abortion- related complications. Most abortions related maternal deaths are attributable to illegal abortions. 13 Accordingly to Ministry of Health Official Statistics, the legal abortion rate remained unchanged in India between 1996 & 2001(three per 1000). In six states annually 2.4 million safe abortions are performed annually in India by formally trained providers in approved facilities, and the safe abortions rate is 10 per 1,000 women & nearly two third of abortions are not performed at approved facilities, indicating that the overall abortions rate is about three times the safe abortions rate. 14
In 2004, pathfinder /India launched the improving access to safe abortion care & services (IASACS) project in selected districts of Northern Karnataka. Kerala is the most advanced state in India demographically and it has the lower fertility level in the country. 15
The tragedy of maternal death is that virtually all are preventable with proper management (WHO, 1986).Recent estimates suggest that around 155 of the more than 500000 pregnancy related deaths in developing countries each year may result from complications of unsafely induced abortion (WHO, 1993) out of an estimated 46 million induced abortions that take place every year in the world, around 19.8 million are unsafe abortions (WHO, 2007). 4
A study was conducted on improving access to safe abortion care and services in Northern Karnataka in seven selected taluks in the Gulbarga, Bellary & Bagalkot districts of Northern Karnataka. A sample of 581 married women aged 15-34 years from rural and urban communities was randomly selected following a two- stage sampling procedure. A sample of 158 women who had an abortion in the last 2 years was selected from both rural and urban communities. A sample of 118 medical providers was randomly selected from a list of all health providers in the study area. Qualitative information was collected through four focus group discussions with married women, eight in –depth interviews with women who had an abortion, and eight in –depth interviews with abortion providers. Information was collected through structured questionnaires in Kannada language. Applying a sampling scheme the mid term assessment was carried out in March & April of 2005. Among 792 married women. About 40% were from urban areas, 40% were from nuclear families, nearly 80% were Hindus, 15% were Muslims, and 25 were
schedule caste. 26% of married women and 49% of all women who had an abortion sought to limit family size. 73% of the abortions was done by D & C, of the 48 medical providers (of 118 total providers) reported performing abortion, only 44 % had undergone abortion. The majority of providers reported taking infection prevention precautions 92% uses gloves , 63 % disposable syringes and needles, 75% antiseptics and 38% proper cleaning of instruments, within a period of less than 1 year, significant changes have been observed 46 % had accepted contraception after abortion. The cost of abortion
also declined by 8% to 10% between the baseline and midterm surveys as reported by both providers and users. 15
The Current medical nursing literature reflects the prevalence of vaginal bleeding in the early pregnancy. Based on the literature and investigation experiences the investigator feels that it is the important to create awareness among the staff nurses to prevent the women’s mortality and morbidity. So the knowledge of the staff nurses may be applied in early recognition of the systems of abortions help in selecting for early medical validation. Hence the investigator planned to impart the knowledge by conducting structured teaching programme to staff nurses.
6.2 REVIEW OF LITERATURE:
Review of Literature is a key step in research process. Review of Literature refers to an extensive, exhaustive and systemative examinations of publications relevant to the research project.16
An evaluative study was conducted on experience seeking abortion among the Unmarried Young Women in Bihar and Jharkhand, among nulliparous young women aged 15 – 24 years who had abortions as the clinic of a leading NGO in Bihar and Jharkhand. Over a 14 month period in 2007-08-246 married and 549 unmarried young abortion seekers were surveyed and 26 who were unmarried were interviewed in depth. Those who were unmarried were for more likely to report non- consensual sexual relation. As many as 25% of unmarried young women compared to only 9% of unmarried young women had a second trimester abortion. The unmarried were far more likely to report non consensual sexual relations leading to pregnancy. After controlling for background factors, finding suggest that unmarried young women were compared to married young women likely to experience second trimester abortion. Programmes need to take steps to improve access to safe and timely abortion for unmarried young women.17
A narrative review of qualitative studies was conducted on women’s experiences of termination of pregnancy and their perspectives on surgical a medical methods in UK. Keyword searches of Medline, CINANL, ISI, and IBSS data bases. Qualitative studies (n=18) on women’s experiences of abortion were identified. Analysis of the results of studies reviewed revealed three main themes experiential aspects of the environment in which termination of pregnancy takes place. Women’s choices about termination of pregnancy are mainly pragmatic ones that are related to negotiating finite personal and family and emotional resources. Women who are well informed and supported in their choices experience good psychosocial out comes from termination of pregnancy. 18
A population based study was conducted on maternal and social factors associated with abortion in India. Birth order specific abortions ratios were calculated using the birth histories of 90,303 ever married women aged 15-49 of years who participated in India National Family Health Survey. Logistic regression was used. The overall abortion ratio was 17.0 per 1,000 pregnancies. The ratio increased from 5.3 per 1,000 pregnancies for first -order births of 25.8 per 1,000 pregnancies for third- order births and then declined. The strongest predictor of abortion was maternal education, women with a least a primary education were more likely than those with no education to have had an abortion (odd ratio: 19-6.7). Rural residence was associated with a reduced
likelihood of abortion (0.6).At the national level; it is likely that unintended pregnancy rather than the sex of the previous child, underlies demand for abortion in India. Rising educational attainment among women may lead to increase in the demand for abortion.19
A prospective descriptive interview based hospital study was conducted on women admitted with septic abortion to evaluate their psychological, demogra-profile in Guru Teg Bahadur Hospital, Delhi. These women were predominantly parous (75%) Hindus (60%), between 20-30 years of age (60%) and mostly married (91.4%) housewives (63.8%). More than 90% already had one or more male child. The contraceptive use was dismally low (23.4%). Large majority (87%) underwent abortion within 3 months of pregnancy. Large family, poverty and spacing were the main reasons cited for abortions. Advanced sepsis and associated medical and surgical complications were present in more than half the patients and 6% succumbed to these problems. Hence education, economic prosperity, easy access to reproductive health facilities and institutional management to sepsis is the key to make abortions safe.20
A North- South comparison study was conducted on socio- demographic determinants of abortion in India. Data from the National Family Health Survey (NFHS2) of India are used to examine the net effects of Social
and demographic characteristics of women on the likelihood of abortion while emphasizing important differences between women from northern and southern states. Southern women have relatively higher levels of literacy and labour force/ participation, low levels of son preference, and smaller family size. Results from logistic regression analysis show that literacy, type of work, belonging to a scheduled caste or tribe, urban residence, standard of living, parity, religion, age, age at union and contraceptive behavior all have significant effects on the likelihood of abortion. However, most of these effects significantly differ for southern and northern women. Moreover, the effects of agricultural work, son preference and age at union on the likelihood of abortion are significant for northern but not southern women. 21