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Unfulfilled commitment

Vinoj Manning, May 12 2017, 23:25 IST

Safe abortion in India

The landmark Medical Termination of Pregnancy (MTP) Act of 1971 legalised abortion in India at a time when it was legal in only 15 countries across the world. By bringing out this Act, the government made a commitment to make abortions available, safe and confidential to the women of our country.

While the Act does not lay down abortion as a woman’s right, it includes “failure of contraception” (in addition to medical and socioeconomic reasons) as a valid indication for availing an abortion, making the choice fairly universal up to 20 weeks of pregnancy. There have been significant transformations in the technological and public health landscape for improving access to safe abortion services in line with the original vision.

The Union government, in a series of steps over the past decade, has recognised and brought comprehensive abortion care (CAC) in the lifecycle approach of public health under the Reproductive, Maternal, Newborn, Child, and Adolescent Health framework. CAC has been integrated with the National Health Mission, which has mandated systematic training of care providers across the country.

In addition, the move has facilitated the implementation and monitoring of the programme to make services accessible. The focus has moved beyond the legal provisions as mandated in the MTP Act to ensuring availability of women-centred CAC services. This change in perspective in policy circles is a reflection of a shifting narrative on abortion, discernible within civil society.

Despite these developments, there is still a need to respond to women’s need for safe abortion services. Recent cases in the Supreme Court bring out the challenges faced by vulnerable women, including survivors of rape, who due to various limiting factors were unable to get safe abortion services within the 20-week gestation limit prescribed by law.

Abortion is a very personal decision for a woman. In India, however, it is often stigmatised. By causing women to seek abortion services through lengthy and complicated court approval processes, we are increasing barriers to women’s access and limiting their right to bodily autonomy.

Technological advancements in the recent past have made abortion a safe and simple outpatient procedure. Medical Abortion (MA), which uses a combination of prescription medications and Manual Vacuum Aspiration (MVA), has presented us with better alternatives. More significantly, it has paved the way for a shift from the dated Dilatation and Curettage (D&C), which requires the use of anaesthesia.

Yet, MA and MVA have not been made extensively available to women, and efforts need to be ramped up for making these new technologies widely available in the public sector. Further, diagnostics have improved manifold over the last few decades making it easier to diagnose foetal abnormalities incompatible with life, which is a very rare occurrence in pregnancy expected in, at most, 2% of all pregnancies.
Awareness about abortion being legal in the country, and of the places offering safe and legal services is very low. The prevailing societal stigma associated with abortion further perpetuates the reluctance of women to not just seek safe abortion services, but also to openly discuss it. If a woman needs an abortion today, can she seek it with as much ease as while going for the treatment of, say, osteoporosis?

Despite the need to perceive abortion through the prism of ‘rights’, we are unable to diminish the stigma which, apart from being archaic, is also disturbingly getting more complex and multi-dimensional owing to the current international discussions and debates on the subject.
As a way forward, there are at least two big areas that need to be worked upon to improve the care-seeking pattern for abortion. First is the need to provide an environment for women to openly talk about their abortion needs. Second, the need to increase availability of CAC services. A big step towards this will be the passage of the suggested amendments to the current MTP Act.

Increasing upper gestation limit

The progressive amendments proposed by the government include provisions for expanding the legal base of providers to comprise nurses and ANMs as well as doctors practising Allopathy, Ayurveda, Homeopathy, Unani and Siddha.
Another important proposal is increasing the upper gestation limit from 20 to 24 weeks for women with vulnerabilities, including survivors of rape and incest, women with disabilities etc., and no upper gestation limit to apply in cases of diagnosed foetal abnormalities incompatible with life.

It is vital to ensure universal, unhindered access to CAC and reaffirm our commitment to creating an enabling environment where women can exercise their reproductive rights. The proposed amendments also include recommendations for the opinion of one provider instead of two in the second trimester in light of new technology and for reducing barriers for women where access to doctors is limited; and for the condition of contraceptive failure to apply to ‘all women’ instead of just ‘married women.’

The proposal to allow trained mid-level providers to offer safe abortion services will significantly improve access, especially in those remote areas where there is no doctor today. However, this needs to be accompanied by concrete operational steps to ensure positive results.
In addition to ensuring high-quality training to the providers, post-training mentorship and follow-up with the providers should be included to ensure service delivery. Both surgical and medical methods should be made widely available to allow a woman to make an informed choice based on her personal context and preference.

Some other proposed amendments to the MTP Act will provide the much required link between a woman seeking an abortion and a facility certified to provide it, such that the option of abortion is available to her as early as possible, and as late as necessary. It is time to implement these policy programme changes to make safe abortion a reality for women in India. It is time we renew our commitment made to women way back in 1971.

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