UNDERSTANDING THE BARRIERS TO ACCESS SAFE ABORTION SERVICES IN INDIA
Vipasha, Junior Research Manager
According to Guttmacher Institute report( 2018),unsafe abortions remain the third leading cause of maternal mortality in India, and close to eight women die each day from related causes. When the number of abortion seekers and the complications from unsafe abortions remain high, then even with the enactment of MTP (Medical Termination of Pregnancy) Act, 1971 why does abortion seems inaccessible for most ? This article attempts to understand the underlying barriers to access safe abortion services in India by taking into account the on ground experiences of two advocates of un-conditional access to abortion services.
The existing health system in a developing country like India is complex and has numerous multi-layered intersections. To facilitate the understanding of barriers, they have been divided here into two broad categories:- Health System Barriers and Arbitrary Conditional Barriers.
Let’s begin with when? where? and the nature of availability? of abortion services in the health system. Dr. Souvik Pyne, (working since 6+ years in the field of abortion advocacy) share that in most rural/district hospitals there is skewed availabilty of gynacelogists which compels many abortion seekers to visit bigger hospitals in Tier one/two cities. Even when they are available conditional access remains a challenge {The All-India Rural Health Statistics (2018–19) indicates there are 1,351 gynaecologists and obstetricians in community health clinics in rural areas across India, and the shortfall is 4,002, i.e., there is a 75% shortage of qualified doctors}. Lack of privacy and confidentiality further widens the gap and pushes abortion seekers towards untrained quacks who provide prompt services and maintain privacy as well as confidentiality their core principles. This aspect of service provision which is critical from a client perspective is ignored by health care professionals and are often upheld by untrained providers. {National Health and Family Survey (2015–16), only 53% of abortions are performed by a registered medical doctor and the balance are conducted by a nurse, auxiliary nurse midwife, dai, family member, or self}
The lack of promotion of available abortion services through Accredited Social Health Activist (ASHA) workers and weak security system at hospitals constitute the arbitrary conditional barriers. Even when the law clearly states that consent of the pregnant person is the essential factor for termination of their pregnancy, in many cases doctor’s at district/rural hospitals have been found to be seeking the consent of the partner in fear of vandalisation/violence at health centres by relatives or community members. Nandini Mazumdar( Assistant Coordinator at Asia Safe Abortion Partnership) mentions about an instance when in “2016–17 hospitals in Delhi were found exploiting the consent form, asking for Aadhar Card of partners.” The barriers to abortion services have an added layer of legal is equal to safe popular conception. Considering the below mentioned references, there however seems to be a necessity to carefully question the legal framework at certain stages- WHO refers in its safe abortion guidelines to replace dilation and curettage¹ method with vacuum aspiration², (D&C) method is still widely practised while conducting surgical abortions in India. Also, for medical abortion usage of pills is only allowed till 9 weeks of pregnancy but WHO recommends it till 12 to 14 weeks for safer abortions.³To bridge the skew availability of ObGyn’s⁴ in urban areas, WHO also recommends to include nurses as medical abortion providers.
The conversation on barriers to abortion services is difficult to comprehend without viewing the attitude of doctors/providers of services. While in conversation with Dr.Pyne who himself hail from a medical background, mention that sub-optimal and disproportionate focus is given to abortion as a topic even after being a very common outcome of pregnancy. The absence of rights based approach is reflected through the apathetic and insensitive/biased attitude of most providers. For example, accessing abortion by a married cis gendered heterosexual woman from an upper/middle class background who doesn’t have a child already might be judged or refused (in certain cases) in comparison to the same accessed by a cis gendered heterosexual married woman from a middle/lower class who already has 2/3 children. In an other scenario- accessing abortion by a queer upper/middle class, unmarried and working person would be faced with discrimination,judgement and diffculty in comparison to cis-gendered heterosexual unmarried and non- working woman. In most cases class, caste, marital status,financial condition and religion of the abortion seeker forms the perception and determines the judgement of the service provider so as to which pregnant person fulfills the qualification to access the service. The moral beliefs and religious affiliations of the service provider and the concerned institution continue to add more layers to the already ailing system. For instance- some local hospitals affiliated and funded by religious insitutions have been found to be awarded more grant in proof of not providing abortion service for a specific period of time.
“Intervention demands a multi-pronged approach”, mentions Dr. Pyne. Building a positive narrative around abortion and considering it as an essential service would require value clarification for doctors at a younger stage of their careers. This would potentially ease the strict binaries towards who should or should not be accessing these services. In context of policy reforms, decriminalisation of Section 312–318 which makes abortion (induced miscarriage) as criminal offence and bringing up more comprehensive policies which do not end up in pushing the individual rights under the bus just to maintain demographic numbers (ex- two child policy or maintaining the sex ratio) should be regarded as crucial for enabling a more accessible environment.
Intervention for abortion services cannot just be limited to providers and seekers. It has to be viewed in a much larger perspective of the international and national political framework. Women’s access to bodily autonomy is largely influenced by the socio-political environment in any country. A liberal and human rights centric political situation might make certain rights accessible versus a rigid and orthodox one. But it can be said that it is only female bodies which are policed and controlled. The intensity of it might differ in different socio-political and cultural contexts and across historical timelines, but the sense of exercising control over them always lingers on. Laws and policies created in silos often come in contradiction with other laws and the people who these laws (abortion rights) impact the most are the ones who are probably under-represented and belong to marginalised genders. Availability, accessibility and quality of services are all knit together with politics of caste, class, gender and religion but advocacy of abortion services should spread in all directions only with the realisation that the ultimate say should be of the pregnant person.
A D&C is a minor surgical procedure to remove tissue from the uterus (womb)
Vacuum or suction aspiration is a procedure that uses a vacuum source to remove an embryo or fetus through the cervix
A medical abortion uses prescription medication given in doses over two or more days to end a pregnancy
OB stands for obstetrician and GYN stands for gynecologist
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