NARINDER NANU AFP / Getty Images Pregnant women wait for a checkup at a government hospital in the Indian city of Amritsar on July 11, 2013

On World Population Day, the first part of TIME’s focus on India — the country with the highest concentration of young people in the world — looked at sex education. This second part examines what happens when the desperate need for contraceptives goes unmet.

Each year, 19 million to 20 million women risk their lives to undergo unsafe abortions, conducted in unsanitary conditions by unqualified practitioners or practitioners who resort to traditional but rudimentary means. Dr. Gilda Sedgh of the Guttmacher Institute, a U.S. sexual-and-reproductive-health-and-advocacy center, believes that “about half of all abortions worldwide are unsafe” — an appalling number when one considers that abortions are simple procedures when done correctly. In India, the problem of unsafe abortions is especially acute. There were 620,472 reported abortions in 2012; experts say the true number of abortions performed in the country could be as high as 7 million, with two-thirds of them taking place outside authorized health facilities. Not all of these are pregnancies out of wedlock. Many unsafe abortions are performed on married women unable to obtain contraception and unable to travel to a registered clinic, who for economic or personal reasons do not wish to have another child.

A woman in India dies every two hours because an abortion goes wrong. That seems like an extraordinary number until one visits the sorts of locations where abortions take place — where it can be seen that the possibility for something to go wrong is high indeed. India’s expenditure on health care is only 3.9% of its gross domestic product, putting it on par with Gabon or the Central African Republic. Rural government clinics are often nothing more than skeletal brick structures with tin roofs and sporadic electricity supply. Women lie on old gurneys or beds if one is available; just as often, they bed down in dark rooms on mud floors scattered with bloody dressings. Less than 20% of these centers provide legitimate abortion facilities, compelling many rural women to seek alternatives.

(MORE: World Population Focus on India, Part 1: Sex Education)

It certainly isn’t tough legislation that’s driving women to backstreet abortionists. Indian abortion laws are liberal — the country is one of only 14 that allow abortion on broad grounds. But misunderstandings about the law and conservative social codes that regard pregnancy out of wedlock as abhorrent mean that many women don’t get help. Aparajita Gogoi, head of the Indian operations of a nonprofit working with women and girls in developing countries, says the “lack of information about services” is particularly debilitating for women and families. Doctors sometimes refuse to perform an abortion on a single woman (as one 22-year-old who was raped and impregnated in Maharashtra discovered), even though that is permissible by law, and girls with unwanted pregnancies can be shunned by their families — sometimes, as in the case of this 17-year-old, with tragic consequences. Fear of social ostracism drives many to take risks. Reflecting a trend seen all over urban India, the city of Gurgaon, near Delhi, is seeing a marked rise in cases of adolescent girls seeking abortions at government hospitals but then vanishing when asked to return with their parents. These are the young women who end up in the backstreet clinics.

Public-health experts promote contraception as protection against unintended pregnancies, but it is not easily available in rural areas, and where it is available, in the towns and cities, young Indians are either embarrassed to ask for it or do not know what to ask for. Because of the lack of sex education, ignorance is rife. A majority of young Indians don’t use protection during their first sexual encounter. One report found that while young men and women knew of contraceptives in general, “knowledge of even one modern non-terminal method such as the condom, the IUD, oral contraceptives and emergency contraception” was reported by far fewer. (Tubectomies for women and, to a much lesser extent, vasectomies for men — both procedures are incentivized by the government — remain India’s preferred modes of contraception.) Along with not knowing, studies have found that even married couples are “shy about seeking sexual and reproductive health services.” At the same time, as with any country that is developing rapidly, sexual patterns are changing and premarital sexual activity is increasing. Add to that a lack of contraceptive information and social sanctions, and “a growing incidence of unintended pregnancy and induced abortion” is the inevitable result, says the Guttmacher Institute’s Sedgh.

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Globally, too, women are not getting the contraceptives they need. The number of women with an unmet need for family planning is projected to grow from 900 million three years ago to 962 million by 2015. This increase, researchers have noted, will be driven by most developing countries. Studies have shown that 82% of unintended pregnancies in developing countries occur among women “who have an unmet need for modern contraception.” There are some glimmers of hope. A study last year estimated that 272,000 maternal fatalities around the world were prevented by contraceptive use, and that India accounted for nearly a third of the averted deaths. But the fact remains that India is home to the most maternal deaths in the world and that 50% of those fatalities are in the 19- to 24-year-old age group. With these sorts of numbers, sex education, contraception and greater health-care spending are simply desirable. They are moral imperatives.

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