Evaluating the Ipas Behavior Change Communication Intervention in ...

Ipas India Country Office P.O. Box 8862, Vasant Vihar, New Delhi 110 057 Email: [email protected] For more information, please contact: Mrs. Paramita Aich ([email protected]), State Program Officer, Jharkhand Mr. Samshad Alam ([email protected]), Senior Program Coordinator, Bihar

Ipas works globally to increase women’s ability to exercise their sexual and reproductive rights and to reduce abortion-related deaths and injuries. We seek to expand the availability, quality, and sustainability of abortion and related reproductive health services, as well as to improve the enabling environment. Ipas believes that no woman should have to risk her life or health because she lacks safe reproductive health choices. Ipas is a registered 501(c)(3) nonprofit organization. All contributions to Ipas are tax deductible to the full extent allowed by law. For more information or to donate to Ipas: Ipas India P.O. Box 8862 Vasant Vihar New Delhi 110 057, India phone: 91.11.4166.2006 fax: 91.11.4166.1711 e-mail: [email protected] © 2012 Ipas. Suggested Citation: Banerjee Sushanta K, Kathryn L. Andersen, Janardan Warvadekar, Sangeeta Batra, & Danish U. Khan 2012. Sharing Messages about Safe Abortion Services: Evaluating the Ipas Behavior Change Communication Intervention in Bihar and Jharkhand, India, New Delhi, Ipas India. Graphic Design: Write Media Produced in India

1 Sharing Messages about Safe Abortion Services

Sharing Messages about Safe Abortion Services Evaluating the Ipas Behavior Change Communication Intervention in Bihar and Jharkhand, India

Sushanta K. Banerjee Kathryn L. Andersen Janardan Warvadekar Sangeeta Batra Danish U. Khan

We are grateful to The David and Lucile Packard Foundation for their support in implementing the CAC program in Bihar and Jharkhand


Contents ACKNOWLEDGEMENTS.................................................................................................................................4 EXECUTIVE SUMMARY..................................................................................................................................6 INTRODUCTION..........................................................................................................................................10 Background.............................................................................................................................................10 Study Objectives......................................................................................................................................11 Setting......................................................................................................................................................12 Implementation.......................................................................................................................................13 STUDY DESIGN AND SAMPLE....................................................................................................................18 Methods...................................................................................................................................................18 Study Design and Sample........................................................................................................................18 Analysis....................................................................................................................................................19 Ethical Issues...........................................................................................................................................20 FINDINGS......................................................................................................................................................21 Socio-demographic Profile of Respondents............................................................................................21 Reproductive History...............................................................................................................................24 Care-seeking and Utilization of Abortion Services..................................................................................25 Abortion-related Information: Sources and Message Recall...................................................................27 Awareness and Knowledge on Abortion-related Issues..........................................................................31 Perceived Availability, Social Norms and Attitude Towards Abortion......................................................33 Intervention Effects on Abortion-related Awareness and Knowledge....................................................33 Effects of the Intervention on Women’s Awareness of the Legality of Abortion: Multivariate Analysis Using the DiD Model.................................................................................................................38 DISCUSSION AND RECOMMENDATIONS.................................................................................................39 Discussion...............................................................................................................................................39 RECOMMENDATIONS..................................................................................................................................43 REFERENCES................................................................................................................................................45 ABBREVIATIONS..........................................................................................................................................48


List of Tables Table 1.1 Socio-demographic characteristics of intervention and comparison districts in Bihar and Jharkhand......................................................................................................................................12 Table 1.2 Types and frequency of BCC and facility-level intervention in HIM and LIM intervention districts in Bihar and Jharkhand........................................................................................17 Table 3.1 Socio-demographic profile of respondents at baseline and endline by type of intervention in Bihar and Jharkhand.................................................................................................22 Table 3.2 Exposure to mass media amongst women at baseline and endline by intervention and comparison districts in Bihar and Jharkhand...................................................................23 Table 3.3 Reproductive history of women at baseline and endline by intervention and comparison districts in Bihar and Jharkhand....................................................................24 Table 3.4 Utilization of abortion services among women who experienced induced abortion in the past three years at baseline and endline by intervention and comparison districts in Bihar and Jharkhand.........................................................................................25 Table 3.5 Types of providers visited and quality of service provision reported by women who experienced induced abortion at baseline and endline by intervention and comparison districts in Bihar and Jharkhand ..............................................................................................26 Table 3.6 Exposure to messages on family planning at baseline and endline by intervention and comparison districts in Bihar and Jharkhand....................................................................27 Table 3.7 Exposure to messages on abortion-related issues at baseline and endline by intervention and comparison districts in Bihar and Jharkhand....................................................................29 Table 3.8 Message recalled by women who reported receiving information on abortion-related issues at endline by intervention and comparison districts in Bihar and Jharkhand...................................30 Table 3.9 Awareness and knowledge on legal aspects and abortion methods at baseline and endline by intervention and comparison districts in Bihar and Jharkhand..................................................31 Table 3.10 Respondent’s attitude and perception about abortion at baseline and endline by intervention and comparison districts in Bihar and Jharkhand districts......................................................32 Table 3.11 Knowledge and awareness of abortion-related issues by frequency of exposure to BCC activities at endline by intervention and comparison districts in Bihar and Jharkhand...............................34 Table 3.12 Effects of intervention on women’s awareness of the legality of abortion and knowledge on safe source and methods using the DiD model.......................................................................................38


Acknowledgements The evaluation studies were successfully completed thanks to the support and involvement of numerous individuals and organizations at different stages of the program implementation and evaluation. We would like to highlight the contribution of everyone who was involved in the survey and made it successful. We are grateful to the governments of Jharkhand and Bihar for their keen interest and collaborative efforts to implement this intervention. The study would not have been possible without the active and continued support of the officials of the Ministry of Health & Family Welfare, Government of Bihar and Jharkhand. We gratefully acknowledge the role of Mr. Sanjay Kumar, Secretary (Health) and Executive Director, State Health Society of Bihar and Ms. Aradhana Patnaik, Mission Director, Jharkhand Rural Health Mission, who continued to provide the support and guidance required. Special thanks are due to Dr. Praveen Chandra, Director in Chief, Department of Health and Family Welfare, Jharkhand; Dr. A.K. Sahi, State Program Officer (Family Planning & IEC), SHS, Bihar; Dr. R.D. Ranjan, Director, SIHFW, Bihar, Dr. Jaya Prasad, Deputy Director, Maternal Health (Nodal officer for MTP), Jharkhand and Dr. Pushpa Maria Beck, Additional Director, Jharkhand, for their contributions at every stage of the implementation. The behavior change communication intervention on CAC was generously supported by the David and Lucile Packard Foundation. We are grateful to the foundation; and, in particular to Mr. V.S. Chandrashekar, Lester Coutinoho, Anupam Shukla and Monica Wahengbam for their support and insights throughout. We sincerely acknowledge the technical guidance of the Ethical Review Committee members and Dr. Rajib Acharaya, Population Council, Dr.Subroto Mondol, Population Foundation of India, Dr. K.B. Saha, Senior Scientist, ICMR, Jabalpur. They voluntarily agreed to review the study design, implementation protocol and research tools prior to the launch of the study.


The study would not have been possible without the constant support of Ms. Paramita Aich, Mr. Tarun Jha and Mr. Samshad Alam, Ipas Jharkhand and Bihar office respectively, who were responsible for the overall monitoring of communication activities. We also appreciate and acknowledge the technical inputs of Ms. Karen Otsea and Ms. Erin Pearson of Ipas US office and Mr. Avindra Mandwal and Mr. Vinoj Manning of Ipas India. An earlier version of this report was reviewed by Ms. Erin Pearson, Ms. Anisha Aggarwal and Mr. Amit Rawat. Their thoughtful comments and insights are much appreciated. We would also like to acknowledge the support of all implementation partners, and in particular, Gram Praudyogik Vikas Sansthan (GPVS), Integrated Development Foundation (IDF), Lohardaga Gram Swarajya Sansthan (LGSS), Azad India Foundation (AIF) and Bangla Natak whose efforts and field insights helped us to better understand the field reality and implement the BCC campaign. The most difficult task of data collection and office editing and data entry and transcription was successfully carried out by the Centre for Media Studies (CMS) and Sigma Research. We appreciate and acknowledge the untiring efforts of CMS. Our heartfelt thanks are due to all research investigators who spent hours in sensitively interviewing the women and meticulously recording quantitative information which form the basis of this research. This acknowledgement cannot be concluded without expressing sincere gratitude to all women, community leaders and health workers who voluntarily spent their time and responded to all questions without any expectation.


Executive Summary

After four decades of the MTP (medical termination of pregnancy) Act, women in India are still seeking abortion care from unqualified providers and dying from unsafe abortion for a variety of reasons. It is estimated that 56% of abortions in India are unsafe and 8-9% of maternal deaths are due to abortionrelated complications. Public health facilities are certified to provide abortion services, but the majority of them do not have a trained medical doctor who legally can provide abortion services. The few public health facilities that have trained and certified providers can not be accessed by women living in villages either due to difficulties in reaching facilities or lack of awareness. In addition, many women are not aware that abortion is legal and available at government facilities. Nor are they aware of the facilities that are certified by the government to provide abortion services. One way to improve women’s knowledge and thereby access to legal abortion services is through behavior change communication (BCC) interventions. Though BCC interventions have successfully been used in India to increase knowledge of contraception, immunization and HIV/AIDS, they have rarely been used to increase awareness on abortion-related

issues. It is evident that the BCC interventions, including mass media, interpersonal communications and outreach activities often improve core health indicators. However, these interventions for large populations are relatively expensive and are only appropriate with sustainable resource support. Evidence is still limited on the relative efficacy of costintensive and low-cost communication interventions. To address the gap that currently exists between the existence of safe abortion services and their use due to lack of community awareness, Ipas India in coordination with the state governments of Bihar and Jharkhand piloted two models of BCC interventions (high-intensity model or HIM and low-intensity model or LIM) in two selected districts each in Bihar and Jharkhand. Both the models aimed at addressing barriers to access to services by enabling public sector sites to offer quality abortion services and by building knowledge and awareness among rural women to access safe and quality abortion services. A multipronged BCC strategy, including IPC (inter personal communication) through group meetings and interactive games, wall signs and street dramas, was introduced in HIM districts. On the other hand, in the LIM districts, the BCC strategy relied on orientation of


community intermediaries and wall signs. A pre-post quasi-experimental research design was adapted to assess the relative efficacy of the BCC interventions in terms of (a) improving communication exposure, knowledge and awareness; (b) utilization of safe abortion services; (c) improving behavioral attributes of abortion services; and (d) association between exposure to communication activities awareness levels. Cross-sectional baseline (2008-09) and endline surveys (2011) were conducted in intervention and comparison districts.

Key Findings Characteristics of the respondents at baseline and endline Women across intervention and comparison districts had comparable reproductive and demographic characteristics, with low levels of education and living standards. The majority of women worked in the house and on family farms and did not have an independent source of income. The study area was predominantly an agricultural community, with restricted mobility and limited exposure to mass media among married women. Religion varied by district, primarily due to the tribal composition of each community. Reproductive characteristics in terms of fertility status and pregnancy loss were almost uniform across all districts. Reports of induced abortion increased between baseline and endline, while other reproductive health characteristics remained stable.

Exposure to abortion-related information The intervention increased women’s exposure to information on abortion-related issues. Message exposure at endline increased significantly in both HIM and LIM districts. Women in the HIM districts

were most commonly exposed to IPC, while women in the LIM districts were most commonly exposed to wall signs and information from their peers. Sources of abortion-related information in comparison districts were mostly informal, including peers and relatives. Women exposed to any of the BCC events in intervention districts uniformly reported one correct message, while every third respondent in comparison districts failed to recall any correct information on abortion-related issues. These differences in message penetration and message recall are most likely to be a result of repeated exposure with formal BCC events.

Knowledge on legal aspects Both the HIM and LIM intervention models improved some aspects of abortion-related knowledge. However, the HIM model was most effective in improving comprehensive knowledge about abortion. The multivariate analysis through DiD estimates showed that after controlling for key sociodemographic characteristics, there were significant improvements in knowledge under the HIM model compared to the comparison group, especially knowledge of the legal status of abortion in India and nearby sources of safe abortion services. The LIM model was relatively less successful in improving knowledge; the only significant difference between the LIM group and the comparison group after controlling for socio-demographic characteristics was increased knowledge about medical abortion methods. A positive linear relationship has been observed between the number of times a woman was exposed to BCC events and increase in knowledge. Frequency of exposure to abortion messaging was highest in the HIM model, which may partially explain the greater success of this model in improving knowledge. This


finding also suggests that to increase knowledge about abortion where levels of knowledge are low, it is important that BCC interventions ensure that women receive multiple exposures to these messages. The data suggest that six formal exposures were needed to increase comprehensive knowledge about abortion issues.

Attitudes and social norms regarding abortion Perceived health risks of unsafe abortion, self-efficacy for family planning and abortion, perceived social norms and social support for abortion within the family increased somewhat between baseline and endline in the intervention districts, while very small changes were observed in the comparison districts. However, other behavioral attributes such as perceived availability and affordability showed no improvement between baseline and endline.

Abortion experience and utilization of services Findings revealed mixed evidence on the utilization of safe abortion services. It was encouraging to note the significant reduction of self-induction at home between baseline and endline. Women reporting induced abortion at home decreased from 32% at baseline to 13% at endline (p