- 48% Out of 48.1 million annual pregnancies, around 48 per cent are unintended and 33 per cent end in abortion
- 26.3% Only 26.3% of all retail chemists in 20 cities spread across Bihar, Maharashtra, Rajasthan and Uttar Pradesh stock medical abortion (MA) drugs, revealed a study conducted by Pratigya Campaign
- 52% abortions are performed in private sector and 20 percent in the public health sector and over 26% of the abortions performed by the woman herself at home; almost 20 per cent end in complication due to unsafe abortions—National Family Health Survey (2015-16)
Kavitha, 32, who has a clinically depressed mother to look after, did not want to have a second child and for weeks sought medical termination of her pregnancy. She knew about the MA (medical abortion) pill, having used it when she conceived within a year of having her first child. As she had her husband’s support then, doctors heeded her request, but this time around nobody was willing to listen, despite her not being mentally prepared to have another child.
In another case last year, a woman caught in an abusive marriage was denied the right to have an abortion as the judge felt it amounted to ‘murder’.
In 2017, a 13-year-old rape victim was denied relief due to red tapism. After the pregnancy crossed 20 weeks, doctors advised against abortion, deeming it risky for the victim.
For a government that waxes eloquent about empowerment of women, it is time it refocused on the need for better family healthcare, particularly legalities over abortion. It is ironic that in an age when live-in relationships are not uncommon and news of sexual assaults clogs the media daily, the law does not recognise the need of both married and unmarried women to have equal access to safe abortion.
“If you look at accessibility, it is a big issue largely because of the way the MTP Act (Medical Termination of Pregnancy Act, 1971) defines who can provide legal and safe abortion services and the place where it can be provided. Often, when a woman seeks abortion, service providers have their own ideas of what is right and what is not,” says V.S. Chandrashekar, CEO, FRHS India, and CAG member, Pratigya Campaign for Gender Equality and Safe Abortion. “While the law permits a married woman to seek abortion due to contraception failure, if an unmarried woman seeks the same, legally the abortion option is not offered to her. That is one big challenge in the law.”
Given the inherent failures in contraception, there will always be a need for abortions. A 2015 study by Guttmacher Institute and Lancet (released in 2017) estimated that out of 48.1 million pregnancies annually in India, around 48 per cent are unintended and 33 per cent end in abortion, The study states that the 15.6 million abortions annually in India compares favourably with all the South Asian countries. Till the ’90s, official estimates pegged annual abortions in India at around 6-6.5 million—a gross underestimation as not all abortions are conducted at approved facilities. Besides increased reporting, the number has risen with the growth in population. Around 81 per cent of abortions are conducted using medical abortion (MA) drugs. Approved for early-stage abortion, the current MA drug is a combination of Mifepristone with Misoprostol. Across the world, it is deemed a safe, effective and simpler option for women who may have otherwise faced barriers in accessing safe abortion care. In 2002, the Medical Termination of Pregnancy (MTP) Rules were amended to enable the provision of medical abortion up to seven weeks gestation, by a registered medical practitioner, as defined by the MTP Act, provided s/he has referral access to a MTP approved health facility.
Accessibility is another handicap. Few options are available in the public sector even though, as per the government programme, even primary health centres can provide abortion services up to seven weeks. Lack of trained providers and facilities mean few of them provide quality abortion services. Even in the private sector, due to requirement of site approval by the state committee, places which provide safe and legal services aren’t many. Physical access to abortion services, thus, is a huge problem.
In such a scenario, the advent of medical abortion drugs provides relief, for a woman is able to take the drug as per recommended protocol and not undergo a procedure. Unfortunately, due to low awareness and lack of correct information, many are not even aware that abortion is legal.
In 2008, the approval of a combination pack (200 mg mifepristone and 800 mcg misoprostol) for medical termination of pregnancy up to nine weeks gestation by the Central Drugs Standard Control Organisation (CDSCO) dramatically changed the landscape for safe abortion in India, with a number of pharmaceutical companies launching MA combipacks. But MA faces a simple hurdle towards being considered a panacea for those seeking hassle-free, early-stage abortion.A study conducted by Pratigya Campaign in 20 cities across four states—Bihar, Maharashtra, Rajasthan and Uttar Pradesh—from September 2018-January 2019, covering 1008 retail chemists revealed that only 26.3 per cent of them stocked MA drugs. While a large number of women access MA from retail drugstores, chemists’ knowledge of MA and its various aspects is quite poor, states the study.
Thus, egregiously, despite many women desiring abortion through medical advice, they are not being able to access the drug as it’s not often in stock. This results in women being forced to seek unsafe medical terminations of pregnancy or opt for undesired additions to the family.
Released in 2017, the fourth round of the National Family Health Survey (2015-16) revealed that three per cent of pregnancies in the five years preceding the survey resulted in abortion. Distressingly, almost one in five women with an abortion (19 per cent) had complications. A majority of the abortions were performed in the private health sector (52 per cent), with 20 per cent performed in the public health sector. Over a quarter (26 per cent) were reportedly performed by the woman herself at home.
Access to a good abortion facility, therefore, is a vital must. “In an ideal world every woman, whether married or unmarried, should have right to abortion. She should also have equal choice of getting it done at a recognised facility. Unfortunately, in India, particularly in rural areas, poorer people don’t have access to free and low-cost, safe abortion services. When it comes to unmarried women, even those from better off backgrounds don’t have access to quality facilities where they can have judgment-free services,” says Vinoj Manning, CEO of the Ipas Development Foundation (IDF) in India. Unlike most other Schedule H drugs (drugs that cannot be purchased over the counter without the prescription of a doctor), there is considerable pressure on checking use of abortion drugs, too, because of the adverse sex ratio. Manning points out that there is a misguided belief among implementers that if you allow the MA pill to be freely available it may lead to increased female foeticide. Other than taking away the choice to have an abortion, it goes against medical facts, for this drug is effective only up to nine weeks of pregnancy, while sex determination tests can only be undertaken after 13-plus weeks. Unfortunately, in states where the government mulishly enforces rules, thus denying women a choice of abortion, the sex ratio remains skewed. Lack of a viable choice is why many turn to self-care or self-use abortion options.
Poonam Muttreja, executive director, Population Foundation of India, points out that according to the Lancet study, only five per cent of abortions in India take place in public health facilities.
“Despite a relatively liberal and longstanding MTP law that governs abortion in India, women continue to suffer the dire consequences of unsafe procedures owing to poor quality of services and the stigma surrounding the issue. While they lack the freedom to plan pregnancies, they also face multiple barriers when they seek abortions,” says Muttreja. The barriers include poor knowledge about safe abortion services and laws, and socio-cultural norms that render abortions taboo and lead to terrible bias among service providers.
To overcome these we need to strengthen safe abortion services as well as enable open conversation so as to banish bias.
Pompy Sridhar, India director, MSD for Mothers, says, “When we talk about decreasing maternal mortality it is primarily about improving quality of services around labour and delivery in the public and private sectors. It is also about quality of primary healthcare, apart from quality of services like abortion, D&C (dilation and curettage procedure) and all those procedures,” says Sridhar. “Unfortunately, in the case of contraceptives, we have found that in most cases the women are unaware of the various devices and this results in their being pushed into using various devices without knowing why one is being changed for another. The world over, there is a cafeteria approach to contraception and it is very evident even in India,” he adds.
In India, contraceptive use and abortions have evolved into a curious relationship. Despite the push to promote contraceptive use, there is a decided lack of awareness about them and its failure often leads to unwanted pregnancy and abortion, which in many cases has become a mode of family planning. To create greater awareness about contraceptives, MSD for Mothers has recently launched a digital solution, ‘Nivi’, to provide information to women on various contraception choices.
During 2014, when a group of experts drew up amendments to the MTP Act, it was proposed that abortion up to 12 weeks should be a right. They felt the need to do away with the requirement of two expert opinions for a second trimester abortion, allowing the opinion of an abortion service provider instead. It also removed the term ‘married’ vis-à-vis seeking an abortion, and sought to increase the number of abortion providers in the country by including nurses, medical ancillary staff and trained alternative medicine practitioners for abortions up to first trimesters.
Experts strongly believe there is a need for a
review of abortion laws, as we remain in a time-warp—the existing law was passed in 1971. Fifty years later, technology has changed, and so have society and the needs of women. Currently, there is need for the law to move from the attitude of a public health protector to keeping women at the centre of its focus. Even today, abortion is not a right women have unquestioningly, but a conditional one—determined by the law and interpreted as such by the service provider or the doctor. There is need to make the abortion law more contemporary by revising amendments that were proposed in 2014 by experts but not tabled in Parliament.
Five years later, there seems to be no move by the government to recognise the right of women to a have a choice to a safe abortion either for medical reasons or for reasons of unwanted pregnancy. By taking away the choice, the existing law could continue to push women to unsafe abortions, which was proven to be the case a few years back, leading to high mortality and morbidity. In denying women the agency over their own bodies, are we awaiting a repeat scenario?