An estimated 15.6 million abortions took place in India in 2015, with the majority of women taking pills at home without adequate counselling, according to a study which found that about half of the pregnancies in the country were unintended.
Published in The Lancet Global Health, the first national study of the incidence of abortion and unintended pregnancy in India found that 15.6 million abortions were performed in the country in 2015.
This translates to an abortion rate of 47 per 1,000 women aged 15?49, which is similar to the abortion rate in neighbouring South Asian countries.
"Women in India face considerable challenges trying to obtain abortion care, including the limited availability of abortion services in public health facilities," said Dr Susheela Singh, vice president for international research at New York?based Guttmacher Institute.
"Our findings suggest that a shortage of trained staff and inadequate supplies and equipment are the primary reasons many public facilities don't provide abortion care," said Singh, co-principal investigator of the study.
Researchers found that the vast majority of abortions (81 per cent) were achieved using medication abortion (which, in India, is commonly referred to as medical methods of abortion, or MMA) that was obtained either from a health facility or another source.
Fourteen per cent of abortions were performed surgically in health facilities, and the remaining five per cent of abortions were performed outside of health facilities using other, typically unsafe, methods.
The study also estimated the incidence of unintended pregnancy in India and found that out of the total 48.1 million pregnancies in 2015, about half were unintended? meaning they were wanted later or not at all.
The estimated unintended pregnancy rate was 70 per 1,000 women aged 1549 in 2015, which is similar to the rates in neighbouring Bangladesh (67) and Nepal (68), and much lower than the rate in Pakistan (93).
"Although abortion has been legal under a broad range of criteria in India since 1971, we have never had a reliable estimate of the number occurring until now," said Dr Chander Shekhar, professor at the International Institute for Population Sciences (IIPS) in Mumbai.
"This new evidence provides policymakers with information that is essential for designing and implementing effective reproductive health care programmes," said Shekhar.
The researchers used two direct methods for measuring incidence. One was compiling national sales and distribution data on MMA (mifepristone and mifepristone-misoprostol combipacks), which represents the vast majority of all abortions in India.
The second was implementing a large-scale survey of public and private health facilities in six states - Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh- where close to half of Indian women of reproductive age live.
Currently, slightly fewer than one in four abortions are provided in health facilities, researchers said.
The public sector - which is the main source of health care for rural and poor women - accounts for only one-quarter of facility-based abortion provision, in part because many public facilities do not offer abortion services.
Close to three in four abortions are achieved using MMA drugs from chemists and informal vendors, rather than from health facilities, researchers said.
They said MMA is safe and effective when used in accordance with World Health Organization guidelines.
For example, according to clinical studies, an MMA regimen that combines misoprostol and mifepristone is 9598 per cent effective when used correctly and within a nine-week gestational limit, they said.
The researchers propose a number of steps to improve the availability and quality of abortion services in health facilities, including training and certifying more doctors to provide abortion care.