Quality services for safe abortion, a matter of rights

Abortion is one of the subjects to be discussed extensively at both national and international levels as it has become controversial all over the world. Everybody is in a dilemma whether a mother has a right to terminate her pregnancy at any time she wishes or an unborn child has a right to life.

The right to life is a very broad concept and is fundamental to all. In India, right to life has been recognised under Article 21 of the Constitution which says that, “No person shall be deprived of his life and personal liberty except according to procedure established by law.”

‘Person’ here includes both man and woman. Among various rights which are available to a woman, the right to abortion is also believed to be one of the most essential and fundamental right. But the question always arises whether an unborn child should be considered as a human being and be given the status of a person or not. There are various aspects such as religious, ethics, moral and legal values that rule over the aspect of right to abortion. Abortion is severely condemned in all religions.

Grounds on which abortion is permitted include: to save the life of the woman, to preserve physical health, to preserve mental health, rape or incest, foetal impairment and economic and social reasons.   

Contraceptive failure on the part of the wife or husband constitutes valid grounds for legal abortion. Unless a medical emergency exists, a legal abortion must be performed during the first 20 weeks of gestation by a registered physician in a hospital established or maintained by the government or in a facility approved by specific legislation.

In general, the consent of the pregnant woman is required before performing an abortion while written consent of her guardian must be obtained for a minor (defined as under age 18) or a mentally retarded woman.

Despite the liberalisation of the abortion law, unsafe abortions have contributed to a high rate of maternal mortality. It is estimated that unsafe abortions account for 20% of maternal deaths in India. 

The legal provisions relating to abortion in India include: a) Indian Penal Code 1860: Abortion is a criminal offence under Section 312 to 316 of IPC 1860; b) The Medical Termination of Pregnancy (MTP) Act 1971: When pregnancies may be terminated by registered medical practitioners is defined under Section 3 of the MTP Act 1971; c) Preconception and Pre-Natal Diagnostic Techniques (Prohibitions of Sex Selection) Act (PCPNDT) 1994: Determination of sex is prohibited under Section 6 of the PCPNDT Act 1994.

Several deficiencies exist in the current legal mechanism.

Public Delivery System: Public delivery system is the main source of healthcare. Private health providers are concentrated in urban and semi-urban areas. Almost all the healthcare providers in rural areas have untrained practitioners without any qualifying degree in any of the streams of medicine.

Infrastructure, human resource availability and unfilled vacancies: Infrastructural and staff shortfalls is a huge problem in India. A reason given for the limited success of state policies is its dependence on the centre for planning and delivery of family welfare services. Despite the initiation of the 24x7 public healthcare and inclusion of expanding the abortion service base in the states, abortion services are not available at public healthcare because they lack either trained staff or the required equipment and supplies.

Training inadequacies as a barrier to quality service provision: Insufficient training on abortion provision, post abortion care, family planning counselling of young couples, emergency contraception and IUD insertion in the public health system. There is lack of knowledge even among doctors who provide abortion services about MTP and PCPNDT Act.

Modifications required in monitoring and supervision: The monitoring and supervision checklist needs modification to capture the areas needing monitoring and focus. Supervisors also need training to adequately mentor their supervisees.

Community awareness
There is lack of knowledge on fertile period, contraceptive methods and availability of reproductive health services in the community. Pregnancies resulting from unprotected sex and forced sex are mostly aborted by untrained abortion providers. It is vital that the community understands the difference between MTP and PCPNDT Act and knows where legal abortion services are available.

Commodity availability: Despite abortion being legal, for some or other reasons doctors are refusing to conduct MTP or are referring clients elsewhere. Medical abortion pills are unavailable in many clinics, hospitals and even in chemist shops.

Public-private partnerships: There is a shortage of qualified staff in the public health delivery system. Public-private partnership thus can assist the public health system. It is common that the poor in remote areas have to travel long distances through unpaved roads and have no money to pay for transport to get the sick to a healthcare centre.

Implementation of the following would be of help:
a) Make abortion law and policy more answerable to the needs and social conditions of women.

b) Placing abortion in the overall context of a comprehensive public health infrastructure and providing good quality services which are physically and financially accessible to all women, should be a priority, irrespective of women’s marital status.

c) The women’s movement needs to debate the issue of abortion beyond the limited context of selective abortion of female foetuses.

d) To make the state answerable to the needs of women, their collective and organised voices have to be heard, taking up advocacy, lobbying and campaigns to make safe abortion women’s rights issue.

e) Research documenting women’s opinions, experiences and aspirations, with widespread dissemination of the findings to ordinary women and men, as well as lobbying by policymakers, NGOs and healthcare providers, are urgent tasks at this juncture.

(The writer is a Senior Advocate of the Supreme Court)