Forty-eight years ago, in 1971, when conversations about women’s reproductive health and rights were still in nascent stages across the world, India became one of the first countries to ensure that women have access to a crucial reproductive health need — that of having a safe, legal abortion.
Today, however, India’s laws and systems have lagged behind and we are doing a great disservice to the women in our country by limiting their control over their wombs because of challenges discussed here.
This International Safe Abortion Day, I want to draw attention to the reality on the ground. The reality, as reported in a study published by the Guttmacher Institute in the Lancet in 2018, is the deplorable level of access to safe abortion. More than 1,56,00,000 abortions take place in India every year, a large number which are considered unsafe. Many pregnant women are circumventing the formal health system by resorting to self-managed medication abortion, or worse, risking unsafe abortions by approaching dubious providers.
Another unfortunate reality is that unsafe abortions continue to be the third-highest cause of maternal deaths in India. The barriers Indian women face and the risks they take to terminate unwanted pregnancies are something very few can imagine, and in my years as a practising gynaecologist, I have seen heartbreaking outcomes that could have easily been prevented.
Today, I appeal to Prime Minister Narendra Modi and his government to give a thought to these urgent concerns.
Make abortion a right
We must trust women to make the best decisions for themselves. India must keep up with international standards, and let a woman decide whether she wants to continue her pregnancy, at least in the first trimester. Then most women will not have to justify why they want to get an abortion done. Most abortions take place in the first trimester and at this stage of pregnancy, it is almost impossible to determine gender, thereby ensuring that the right to abortion is not misused to terminate pregnancies based on the sex of the fetus — an issue I know the government is concerned with.
The fear of sex-selective abortion should not be used to justify why pregnant women should be stripped of their basic reproductive rights.
It is time women have this right over their own bodies and the ability to decide on their own health and well-being.
Increase access to medication abortion
The Guttmacher study showed that most abortions in India are carried out through medication – a majority of these taking place outside government-approved health facilities. With a limited pool of qualified doctors and hampered access to health facilities, women have little choice but to self-manage their abortions using abortion drugs from pharmacies.
To provide pregnant women with safe, affordable options closer to their homes, the government must consider bringing in mid-level healthcare providers, including nurses and AYUSH doctors, to provide medication abortion up to nine weeks, as is recommended by the World Health Organisation. These providers have been entrusted with running our public health facilities and provide services that are far more complicated than medication abortion. Taking even a small step like that of amending the dated Medical Termination of Pregnancy (MTP) Act, 1971 to allow mid-level providers to provide medication abortion in just public health facilities, can be the game changer for women’s access to safe abortion in India.
MTP Additionally, a small tweak in the MTP Rules to allow all MBBS doctors to provide medication abortion will go a long way in addressing the supply shortfall of healthcare professionals. These inclusions will also give us the opportunity of counselling and providing post-abortion contraception to all those women who otherwise miss out on these when their only choice is to self-manage their abortion.
Allow abortion after 20 weeks in special cases
In the last few years, we have heard of umpteen cases where our courts either granted or denied women their permission to terminate unwanted pregnancies. There are two factors that such judgments are related to. First, doctors in India today are armed with technology much superior to what was available when abortion was legalised in 1971. This allows the diagnosis of serious abnormalities in a fetus.
Second, there are cases where pregnant rape survivors come forward much later than the mandated 20 weeks. Women in these distressing situations then have to leave it to the courts to determine their fate, a process that only compounds their trauma.
Amendments in the MTP Act to address this have already been proposed. In 2017, the National Commission for Women recommended increasing the abortion time limit from 20 weeks to 24 weeks for rape survivors and other vulnerable pregnant women. As a member of the committee that worked on suggesting these amendments, I urge the government to give serious consideration to this proposition.
In the tragic cases of young girls surviving rape, I believe Section 5 of the MTP Act allows termination of pregnancy at any point to save the survivor’s life. According to the WHO, young girls below the age of 14 years face a higher risk of complications and five times the risk of death as a result of pregnancy than other women – and this, I believe, qualifies the case of these young girls to fall under Section 5 of the MTP Act.
In cases where the fetus has little chance of survival or could lead a life of suffering after being born, the government needs to allow termination of the pregnancy at any point of gestation. I also appeal to the government that they gazette a list of fetal abnormalities that are incompatible with life or would require major medical interventions to survive that doctors and health facilities can refer to.
Abortion — a right not privilege
In today’s day and age, women should not be at the mercy of a system that provides this essential service as a privilege. In a country like India, which is sensitive to women’s needs, abortion should be an absolute right. This will not only go a long way in empowering women, but also take us to the next level of accomplishing the UN’s Sustainable Development Goals related to maternal mortality.
The solutions to each of these abortion-related challenges have already been suggested in the proposed amendments to the MTP Act. I urge the government to resist partisan pressures and see to it that these recommendations are legislated with immediate effect.
There is one thing I am absolutely sure of — women who want or need an abortion will find one way or the other to get it done. The question is whether we are there to support them with the rights they rightfully deserve.
The world is watching India — let us once again be the guardians of women’s health and rights.
The author is a gynaecologist and the former secretary-general of the Federation of Obstetric and Gynecological Societies of India and member, Technical Advisory Group, SEARO, WHO. Views are personal.