2020 was the Annus Horribilis. The COVID-19 pandemic shook the foundations of our world. When many world leaders equated the preparations to tackle the pandemic to a war footing and asked the public to make collective sacrifices, little did we all delve into those exaggerated declarations from the leaders to sift through and analyze how best are the leaders equipping their countries to tackle the pandemic. In the initial months of the pandemic, as different countries declared different timelines for total lockdown, there was little clarity about what is essential and not essential services. Amidst all the chaos, it came across as if the government expected that all bodily functions such as menstruation, pregnancy can all be on pause mode during the pandemic!
In India, in the first weeks of the lockdown when the whole country was brought to a standstill, when the busiest of the busy roads were as empty as a clear blue sky, when people would get out of their houses only to buy groceries and medicines, there were a group of outraged netizens and activists who brought to the leaders’ attention that basic menstrual hygiene products were not declared as essential goods! After numerous likes, shares, comments, retweets amplification in the net world, knocks on the government’s doors became so loud that eventually it was declared by the government that menstrual hygiene products are essential too! Meanwhile, numerous people in the country were being turned away from hospitals and clinics when they wanted an abortion during the lockdown. The reason for denying them abortion: not an essential service!
Well, war cry indeed, citizens, activists and NGOs made to have the abortion declared as an essential service and essential service thus it became, but how many in fact were able to get a safe and legal abortion during the lockdown and post lockdown, even though abortion was declared as an essential service?
As part of the Safe Abortion Action Fund (SAAF), in the initial weeks of the unlock in India, Hidden Pockets Collective did a tele-audit of hospitals and clinics in four districts of Karnataka viz Bengaluru Urban, Mysore, Shimoga and Ballari. We wanted to find out whether safe, legal and most importantly non-judgemental abortion especially for single women, continues to be out of bounds even during the pandemic when unplanned pregnancies are on the rise. The findings were worrisome.
With the year almost ending now, and more than 6 months have passed since the initial weeks of unlock, we set out for another round of tele-audit calls to see how have the access and availability of safe, legal and non-judgemental abortion improved/ restored in this time duration. The findings were a mixed bag!
Dr. A from a leading private hospital in Ballari, whom we had spoken to in the first round of tele-audits in June/ July, where she came across as very sympathetic to the challenges in accessing safe and legal termination of pregnancies and even agreed to provide MMA (Medically Managed Abortion) for single women under 7 weeks of gestation, was triggered this time when we used the word non-judgemental abortion! She blasted at us and said that she has been getting numerous cases in these last few months where women came to her for MMA pills and they keep coming back to her repeatedly, instead of taking contraceptives. She said these women are “serial abortionists” and she will not give non-judgemental abortion but give them an earful for not using contraceptives. To quote her further, “You want a non-judgemental abortion? Well, I will make sure I give these women a hard lesson when they come to me for abortion.”
When we reminded Dr. A how open and understanding she was when we last spoke to her, she said, “Agreed. But I will not want this hospital as a safe and non-judgemental space for women to get abortions. This is not a walk-in and walk-out space where they all can come, take the pill and have an abortion and keep coming back again and again.”
At our repeated presentation of facts that the pandemic, especially the lockdown, has worsened many people’s access to contraceptives and many doctors are not helping them to get a safe and legal abortion and that forces them to approach quacks, Dr. A had a pat reply: “These women are not dumb. They are smart enough to know where to get an abortion. If they were so worried about pregnancy, they should have made it a priority to use contraception.” She strongly said that she will not help women get an abortion and questioned us with, “Do you realize what is an abortion? It is killing a baby! You are baby killers!”
Dr. A was firm on her new stand that neither she nor the hospital that she works for will give any abortion. As the last word she said, “If you need help and support to give women good guidance and counselling on contraceptives, they can come here. But I shall not be a party to give women abortion. They keep coming back here, again and again, with some silly excuses or the other for not taking contraceptives. I will make it a point to give them a good hearing henceforth so that they don’t come back here ever again for abortion.”
Pharmacies: the shortcut to abortion
Dr. B from a well reputed private hospital in Shimoga was far more approachable and less guarded since our last call. She said that women, married or unmarried can get a safe, legal and non-judgemental abortion at the hospital. Bracing for the second wave of the pandemic, she said that if the pregnancy is above 20 weeks, the concerned parties will need to move legally, that is through a notarized legal affidavit which needs to be filed in and abortion can proceed only through legal sanction.
For unmarried women, she reiterated her statements from our earlier calls that it is best that her parents are involved. She again recounted numerous incidents as in the earlier calls, where women were abandoned by their male company or them creating scenes in the hospital. She also narrated a recent incident wherein a couple who were engaged to be married had come for an abortion and the fiancé had abandoned the woman. The hospital was left with no option but to inform her parents as consent was needed for surgical procedures.
When we posed the question that if women are not in a position to involve her parents, Dr B. answered that any female close relatives like a sister will be sufficient. We asked her that
even if that is not a possibility but an organization that works in SRHR is there as a patient bystander to take care of the woman, she said that is also okay, as long as the NGO is legal and the proof for registration etc are submitted when the woman needs legalized consent such as in the case of surgeries. She highlighted that the hospital has given abortion to unmarried women too in these past months, and all the hospital is aiming for by having these systems in place is that they want minimal trouble by preventing patient abandonment.
Dr. B shared with us a pattern she has seen emerge during these last few months. She said she has had numerous cases where single women self-administered medical abortion pills and developed complications in abortion. On asking these women where they got the medical abortion pills from they said that they procured it from the pharmacies. Dr. B said that perhaps these women found it difficult to approach a doctor to get abortion due to the cultural taboo, or could be that they wanted to cut the costs of medical expenses that they can incur when they get an abortion done through a doctor at a hospital. Whatever may the reason be, Dr. B said it is highly risky as women take these medical abortion pills without any medical supervision. She elaborated on various complicated cases she had to intervene because the women took the medications all wrong, sometimes even overdosing. She suggested that something needs to be done such that pharmacies do not continue dispensing medical abortion pills without medical supervision. In exasperation she explained how in the end, it is always the doctors like her, who have to handle the complications and save the women’s lives when such ill advised and non supervised usage of medical abortion pills occur.
The POCSO dilemmas and love:
Dr. C, a doctor at a government hospital in Mysore, whom we spoke to for the first time in our audits, came as a breath of fresh air. In our earlier audits in June/July we had no response from any government hospital in Mysore. However, in our December calls, we were finally able to have a breakthrough.
For Dr. C, conversations on safe, legal and non-judgemental abortion for women (single or married) were all irrelevant as she said the government hospital is the go-to place for any woman. What she wanted to bring to our notice was that in these last few months there were increasing cases of minors who had come to the hospital for abortion! She said, in many cases she was put in a difficult position due to specifics of certain cases such as two adolescents who are in love or just wanted to explore sexual matters, but she had to report the matter to the police according to the laws of the country, such as the Protection of Children from Sexual Offences (POCSO) Act. The problematic part of POCSO is that those adolescents who have had consensual sex, are in fact punishable! And to add more woe to the misery, the legal age of consent in the country is in fact 18. Dr. C opined that laws in the country should change to validate consensual sex amongst adolescents because she strongly felt that the adolescents suffer social stigma and ostracization all due to the punitive nature of the POCSO Act.
Too hectic! Too busy?
The government hospitals in Bengaluru Urban, be it the referral hospitals or the maternity hospitals or the tertiary hospitals, must have had hectic days in these last few months because most of them still did not have responsive landlines. If at all the phone did get picked up, the receiver had no clue about abortion details that the hospital provided. And to talk to the doctor was just impossible as she/he was either in the O.T or in the ward rounds. Requests for the personal number of the doctors were met with the replies “not possible.”
The second wave of infection is looming ahead. Vaccinations are planned to be rolled out on a priority basis as determined by the government. Questions are always remaining whether there will be another lockdown in the coming months, whether it will just be a night curfew. Whatever may the events be, one thing that needs to be planned well ahead of time by the government who constantly espouses war footing to tackle the pandemic is: women should have access to a safe, legal and non-judgemental abortion because abortion is a time sensitive matter.
Dr. Nishitha Aysha Ashraf is Programme Associate for SAAF Project at the Hidden Pockets Collective. She completed her B.A. Journalism & Communication (2010) and Bachelor of Dental Surgery (2015) from Manipal, Karnataka. She has covered the Nipah outbreak in Kerala during her stint as Health Reporter with The News Minute (2018). The reportage furthered her interest to be a key player in public health/ community health. Her internship and work at SOCHARA – Society for Community Health Awareness, Research and Action (2019) was instrumental to learn more about the People’s Health Movement. She is keen on exploring the SRHR issues of Kerala, especially those amongst the Muslim and Christian communities.
The Medical Termination of Pregnancy (Amendment) Bill, 2020
The new Medical Termination of Pregnancy bill 202 was passed in the Lok Sabha in March 2020 and Rajya Sabha in March 2021.
Highlights of the bill:
- Currently, abortion requires the opinion of one doctor if it is done within 12 weeks of conception and two doctors if it is done between 12 and 20 weeks. The Bill allows abortion to be done on the advice of one doctor up to 20 weeks, and two doctors in the case of certain categories of women between 20 and 24 weeks.
- The Bill sets up state level Medical Boards to decide if a pregnancy may be terminated after 24 weeks in cases of substantial foetal abnormalities. All state and union territory governments will constitute a Medical Board. The Board will decide if a pregnancy may be terminated after 24 weeks due to substantial foetal abnormalities. Each Board will have a gynaecologist, paediatrician, radiologist/sonologist, and other members notified by the state government.
- The Act specifies the grounds for terminating a pregnancy and specifies the time limit for terminating a pregnancy.
- Under the Act a pregnancy may be terminated up to 20 weeks by a married woman in the case of failure of contraceptive method or device. The Bill allows unmarried women to also terminate a pregnancy for this reason.
- A registered medical practitioner may only reveal the details of a woman whose pregnancy has been terminated to a person authorised by law. Violation is punishable with imprisonment up to a year, a fine, or both.