Table 2 Thematic analysis of in-depth interviews with faculty of the department of obstetrics and gynaecology regarding reproductive rights for family planning and abortion services as per sub-components of the COM-B framework
Theme and Sub theme | Codes | Verbatims | COM-B subcomponents | Categories | ||
|---|---|---|---|---|---|---|
I. Reproductive rights-based family planning services | ||||||
Facilitators | ||||||
Availability of family planning methods | Regular supply of contraceptive methods | We utilize funds given to deptartment under JSSK (Janani Suraksha Yojana Karayakaram) scheme we ensure that 4 months supply is available I don’t remember any shortfall in my practice | Physical Opportunity | Institute level | ||
Access to family planning methods | Availability of invasive and non invasive methods | OCP(Oral Contraceptive Pill) we give, For CuT they come to medical college. For invasive techniques, they come | Physical Opportunity | Institute level | ||
Informed care through counselling by counsellors and preference for using contraceptive method is considered | Availability of counsellor | We have a counsellor: RMNCHA (reproductive maternal newborn child and adolescent health) counsellor and separate family planning counsellors | Physical Opportunity | Service provider (SP) Level and institute level | ||
Choice of contraceptive offered, FP stamp for counselling on card | We stamp the card also. We have a stamp made for family planning counselling. A seal is there in the ANC (antenatal care) card indicating her preference We are not forcing any one for contraception and we are giving them cafeteria of services | Automatic motivation | SP level | |||
Re-enforced counselling on multiple occasions | So counselling is done during that period other- wise antenatal visit and pre labor conditions, if we could not counsel with in that period we also counsel her after delivery with- in 48 h, that is post- partum insertion, There are pamphlets in OPD (outpatient department) and labor room, social worker counsel about PPIUCD (postpartum intrauterine device) insertion in OPD and labor room | Reflective Motivation | SP level | |||
Consented care | Consent obtained before insertion of PPIUCD Woman’s consent is given importance | We are taking informed consent of the client when she is not in labor just before insertion of PPIUCD consent is taken We have consent forms from government of Rajasthan. We have separate consent forms. In form the “Labharti” means the client has to sign the doctor has to sign and monetary benefits are also displayed. so that the patient is aware of everything. Record is maintained for that and one kept with us and other is given to the client only her consent we consider we don’t even consider her husband or relatives consent. We have a format for the consent Signature is taken before delivery and then countersignature | Reflective Motivation | SP level | ||
Right to privacy and confidentiality | Maintaining auditory and visual privacy | Yes, in our antenatal clinic there is interaction of patient with single doctor one by one. We take her for exam, where curtain is there. We take care of their privacy. | Physical Opportunity | SP level and institute level | ||
Evidence based quality family planning services using MEC wheel/eligibility checklist | Eligibility checklist used for selective procedure | Yes, if you are including the sterilization and these operations also, then there’s a booklet which is having all the things, whether what has the patient been checked for, whether she is suitable for it or not. And there’s the sign of the service provider also whether he has checked all the things or not. And in Cu-T or whatever FP we are using, there’s a checklist, after checking that checklist for a particular contraceptive method | Reflective Motivation | Service provider level | ||
Used for teaching purpose | We have MEC (medical eligibility criteria) wheel with us, it is part of their lectures, we included MEC wheel during the injectable contraceptive training. We show them in all lectures on FP. | Reflective Motivation | Service provider level | |||
MEC wheel followed at rural health training centers (RHTC) and primary health centers’s (PHC) level/para medical staff | OBG (obstetrics and gynaecology), RHTC and PHC level staff usually use it, ANM (auxiliary nurse midwife) and ASHA (accredited social health activist) bring them on duty. LHVs (lady health visitors) have checklist, they are trained to used it. | Reflective Motivation | Institute level | |||
Helps to counsel and assist to choose, before provision of contraceptive services | WHO MEC wheel, we have RMNCHA counsellors who are doing contraceptive counselling to all the patients | Reflective Motivation | Service provider level | |||
Barriers to rights-based family planning services | ||||||
Lack of privacy and confidentiality | Infrastructural gaps in space, and time constraints | It is very challenging, in a public hospital to ensure the right of every women visiting because at times infrastructure do not support, we don’t have sufficient manpower to deal with, we are trying to raise the gap and do as far as possible from our side. Auditory privacy is not maintained | Physical Opportunity | Institute level | ||
Heavy rush of patients | In OPD it is difficult because large chunk of patients are there, for counselling purpose, counselling is more of a health education type so that can be done in a group, one to one counselling patient wants to have, or wants to tell something, which need not to be disclosed to other patients, she can very well come have one to one conversation. | |||||
Shortage of human resources | “We are working with 50% staff, it is not possible for me to sit in OPD and ask the watch man to send one patient at a time, that is possible if we are fully staffed only then we can maintain their privacy. At present doctor patient ratio is not maintained, here one OPD is managed by one watchman” “We have number of examination rooms, but we are running critically short of faculty, with such good work 15–20 deliveries in a day we do have infrastructure but require more faculty to handle things and privacy issues. There are just 2 nursing staff. who are taking care of ANC, infertility clinic, Gynae clinic and cancer patients, how is it possible. That has to be taken care of by the authorities.” | Physical Opportunity | Institute level | |||
Management problems | “I think you have seen the OPD, it is as private as it can get in a government hospital. We have separate cubical for examination, but patients just open the door and walk in, we are trying to maintain it. Huge rush can be managed by the line system if strictly maintained. We are trying to do that but not yet achieved success” | Physical Opportunity | Institute level | |||
Lack of use of evidence based medical eligible checklist or MEC wheel | MEC wheel/checklist not used | Clinical eligibility assessed from memory and experience through verbal questioning | Automatic Motivation | Service provider level | ||
I am doing that by my experience and not using MEC, we usually do not insist up on a base of checklist, we conjure the information and decides on our own, | Automatic Motivation | Service provider level | ||||
Shortage of MEC wheel | we don’t have wheels, criteria we do it from our memory | Automatic Motivation | Service provider level | |||
Lack of awareness and training of counsellors of MEC Wheel. | MEC wheel not aware of, we assess but eligibility wheel not used. But I don’t think they are sensitized to use the wheel, they are basically trained by the state government | Physical Capability | Institute level | |||
II. Reproductive rights-based abortion care services | ||||||
Facilitators of provision of safe abortion services | ||||||
Availability and accessibility of abortion services | Abortion services are available and accessible for all the women irrespective of duration of gestation | Abortion is freely provided, ours is the only center where we get patients from private facilities and other sectors, they come only for second trimester abortion with anomalies, with failed or retained products in uterus. As many a times the MTP(medical termination of pregnancy) is done outside without the supervision of the Gynecologist as the women directly take them (MTP drugs) from the chemist. Often a failure or retained products is the common presentation in the outpatient department | Physical Opportunity | Institute level | ||
Follow up is ensured for medical abortion | Medical method is chosen if women can come for follow up in case of complication arising of abortion | We see the compliance of women and follow up, she should not be lost to follow up, if we give MTP pill it is seen that she is coming for the subsequent visits to know completion of abortion, If we are sure enough that patient can come again to us or any health provider if any complication is there or she can be under follow up, then we advise medical method of abortion | Physical Opportunity | Institute level | ||
Informed consent of women | Consent of woman only required | Only her (client) consent is obtained. She is an adult she can give consent. We don’t insist on bringing a relative or anyone else. Surgical procedure requires one person along. Only client’s consent is required, it is her reproductive right. We are not going to un-necessarily harass her, but there has been case against doctor, therefore preferably if anyone is there if any complications happens but it is not mandatory, no need of anyone else, only her wish and consent is required. | Psychological Capability | Patient level | ||
Provision of quality services | Standard protocols followed | We investigate and get the USG (ultrasonography) done before abortion [as per the protocol] | Psychological Capability | Service provider level | ||
Medical or surgical abortion as per gestational age or patient choice and offer accordingly medical abortion, MVA or Dilation and Evacuation (D&E) | Reflective Motivation | Service provider level | ||||
Respect for reproductive rights of women to avail abortion services | Belief in reproductive rights of women as per her legal age | As per MTP law if she is a major she has all the righst, we would not separate her from any other married women who seek abortion we just counsel her regarding method and whatever she selects is given to her | Reflective Motivation | Service provider level | ||
She has the right to terminate her pregnancy, she can give the consent | Reflective Motivation | Service provider level | ||||
She is an adult, she can give consent, usually opt for medical abortion, if she says it’s a consensual thing and no rape then it can be given | Social Opportunity | Service provider level | ||||
Barriers of provision of safe abortion services | ||||||
Lack of access to free medical abortion services | Out of pocket expenditure on buying medicines for medical abortion | “Client has to buy from outside. MTP kit is not available in government supply. she has to buy for it for 550 rupees (USD 6.8), if she can then we ask her to buy, if she cannot then suction evacuation is always there.” | Physical Opportunity | Institute level | ||
“Misoprostol is available, mifepristone is not” | ||||||
Lack of accessibility of medical abortion to women from remote areas | Restricted access to medical abortion for women in the remote villages | In case the patient is coming from remote village, or we are sure that the patient will not come for follow up or she will not consult any doctor if any complication is arising, then we will definitely opt for Manual Vaccum Aspiration (MVA) or surgical method. | Automatic Motivation | Service provider level | ||
Requirement of accompanying person | Delayed services due to need for accompanying family member for fear of complications | We first see them in OPD, it’s not like we do the procedure on the same day, we ask the patient to come on empty stomach the next day by 8 o clock and with a relative, not necessarily husband, we do like to have attendant for consent, consent of the women and the attendant in case some-thing goes wrong. Someone is required, in case sedation is given and any complication arise so we ask the relative to stay back. If no-one is there then we ask her to bring some one, and they return in 2–3 days | ||||
Husband consent is required for abortion with sterlization | Requirement of additional consent of husband in case of abortion with tubal ligation | A written consent is taken. We take her consent if the husband is available then we take his consent as well, for tubal ligation his consent is taken, for plain MTP we don’t. | ||||
Restriction and fear by law in case of unmarried girls due to its being a medicolegal case and complications | Fear of medico legal case in case of unmarried girl | With fear of MLC (medico-legal case) they don’t go for abortion. Even if the girl says that I have done with my own consent the relatives say that no it was not her consent. The parents of the girl also know that it is going on and she fears. If she refuses also we have to tell the parents, but by chance if complication occurs then consent is necessary, nowadays allegations are on doctors and everyone wants to be safe. | Automatic Motivation | Service provider level | ||
Mandatory police notification to be done and court permission is required in unmarried girls | Inform police /jurist in MLC cases. Inform police in all unmarried cases. In unmarried cases we go as per medico legal procedure, for that we need to take the permission of the court, weather of termination of pregnancy is to be done, we have to follow the court, we have to follow the directive of the court. | Reflective Motivation | Service provider level | |||
Documentary confirmation of age in unmarried girls | we have to check if she is 19, below 18 then we have to inform police, and we have to see that with her consent, she or her parents are not ready for case then we can do. We have to take consent | Psychological Capability | Service provider level | |||
Consent of family required in case of unmarried girls | Consent of parents or relative is needed Keep parents and relatives in confidence in high risk pregnancy Relatives are called for fear of complication | Reflective Motivation | Service provider level | |||
Requirement of presence of family member | she should not be alone, if some mishap happens them she should have someone who can attend. Consent is hers only, we admit for medical and also call family member | Reflective Motivation | Service provider level | |||