Nirdhāra: a multi-method study of women’s abortion trajectories in Karnataka, India

Abstract

Embedded in critical feminist and reproductive justice literature and influenced by feminist and anthropological approaches, my PhD research centred women’s [1] lived realities to examine women’s abortion trajectories [2] in rural South India. This approach significantly departs from the dominant biomedical or public health approaches to abortion prevalent in the literature.

Using a multi-method research design, my PhD analysed how access to resources, timing, knowledge, and norms surrounding sexuality and womanhood shape abortion care-seeking, access and provision. I drew on data collected over nine months in Bagalkot and Belgaum districts in Karnataka, India. I conducted in-depth interviews with women who had an abortion (including self-managed) (n= 31) and, using a nested design, collected questionnaire data on Community Health Intermediaries (CHIs) (n= 112), followed by in-depth interviews (n= 21) with a sub-sample of CHIs. I traced the construction of “womanhood” and “fertility” in relevant population and health policies in India and then, using the collected empirical data, I “studied up” abortion-related policies.

My thesis contributes new empirical data, theoretical concepts, methodological innovations, and policy-relevant findings. Empirically, it offers new data on women’s abortion experiences and management, including self-management. Data on self-managed abortions have been difficult to collect, making this a particularly unique and valuable contribution to the literature. My thesis also offers new data on CHIs’ attitudes to and beliefs about abortion, providing a reconceptulisation of the roles CHIs play in abortion-related care provision.

Theoretically, my thesis critiques linear constructions of women’s abortion trajectories; finding that women simultaneously deploy multiple strategies to access abortion care and encounter a range of barriers. Women who self-manage, unlike those interacting with (in)formal health systems, report fewer delays and disruptions. Women’s abortion trajectories underscore the myriad, complex ways in which they exercise agency and resist forms of control. I offer new theorisations of abortion self-management, and utilising the “Three Delays Model[3]”, I demonstrate the impact of delays on women’s abortion experiences. My thesis also highlighted the different roles CHIs play at different points in women’s care trajectories, challenging the disjointed and technical approaches to task-sharing programmes currently applied in global health. Using a socio-ecological framework, I demonstrated how stigma, lack of abortion-related knowledge, and fear interact and shape abortion trajectories.

Using the concept of “reproductive governance[4]”, I analysed India’s population and health policies, demonstrating how normative constructions of sexuality and womanhood are embedded in abortion policies, reproducing abortion stigma and shaping who accesses abortion under which conditions. This has particular implications for the regulation of abortion self-management, recognising it as a site of policy contestation requiring urgent attention. This critical reading and “studying up” of policies also uncovers the prevailing bio-medical frames that shape abortion care provision and access. By centring women, my thesis rejected biomedical and linear constructions of women’s abortion experiences; offering conceptual insights for abortion care provision, understandings of abortion safety and quality of care, and abortion policy framing.

I successfully defended (November 2019) and was awarded (with no corrections) my PhD in January 2020. Drawing on CHI data, I published a single-authored article in the highly cited and peer-reviewed journal Social Science and Medicine. A book chapter published in 2022 locates women’s abortion trajectories within their longer reproductive lifecourse, including contentions with sterilisation. I am currently preparing more articles from my PhD research for publication, along with producing impact resources for policy and advocacy audiences.

—

[1] Pregnant persons- trans men, non binary persons, and cis-gender women, amongst others- all want and seek abortion care. I use women here to specifically refer to cis-gender women as this is the population I captured in my data collection. I do not wish to misrepresent these data or make invisible the additional barriers and forms of violence that trans men and non-binary folks may encounter over the course of their trajectories.

[2] Abortion trajectories are complex, non-linear processes embedded within larger social and structural relationships and interactions (Coast et al., 2018).

[3] The Three Delays Model was conceptualised by Thaddeus and Maine (1994), and explores how delays in decision-making, care-seeking, and care-provision contribute to maternal mortality.

[4] Reproductive Governance, developed by Morgan and Roberts (2012), is an analytical tool to trace the shifting political rationalities of population and reproduction.