Soar: Two-Child-Policy! Shrug: ICPD 1994…

On 7 February 2020, a bill on the Two-Child-Policy was introduced as a private member bill in the Rajya Sabha by the Member of Parliament Anil Desai. This is a Constitution (Amendment) Bill and seeks to bring amendments to article 47. The short title of the bill is ‘Duty of the State to promote small family norm’. The main objective of the amendment is to enforce punitive measures for those families who have more than two children. The new article is suggested to be inserted at the end of article 47 and is as follows:

“The State shall promote small family norms by offering incentives in taxes, employment, education etc to its people who keep their family limited to two children and shall withdraw every concession from and deprive such incentives to those not adhering to small family norm, to keep the growing population under control.”

The bill elaborates further in the statement of objects and reasons about the need to control population explosion and where India currently stands in the global ranking in relation to the rate of population growth, population density. The details stated further in the bill with respect to Two-Child –Policy is as follows:

‘Today, there is also a need to encourage the people to keep small family by offering tax concessions, priority in social benefit schemes and school admissions etc. And at the same time discourage them from producing more children by withdrawing tax concessions, imposing heavy taxes and by making other punitive provisions for violations.”

This is not the first time such a bill has been introduced in the Parliament.

Earlier it was the Population Regulation Bill 2019 that stirred up controversy with its draconian approach to enforce the Two-Child-Policy.  It had strong punitive measures such as people being disqualified to contest in elections to either Houses of Parliament or state legislative assembly or even bodies of the local self-government. The bill also proposed that every serving government employee ought to give an undertaking that they shall not have more than two children. The penalties for anyone who contravenes the policy will be a reduction in subsidies on loans, lower interest rates on savings schemes in banks and investments, higher interest rates for availing loans from banks and financial institutions, reduction in benefits of Public Distribution System.  Also, incentives are placed for employees of Central Government and Public Sector Enterprises under the Central Government if they or their spouses undergo sterilization.

Matters even reached the President Ram Nath Kovind way before it should have taken the defined course of bills and the Parliament. In an unprecedented move, 125 members of the Parliament (1) signed a petition for the Two-Child-Policy and had it submitted to the President, even though the President has no role in suggesting, introducing or implementing public policy in India (2). In response to the petition, the Population Foundation of India put out a statement (3) from the Advocating Reproductive Choices (ARC) – a coalition of 165 civil society organizations and individuals- and denounced the Two-Child-Policy as going against the national interest, violating basic tenets of fundamental human rights and the Indian Constitution.

A matter to be noted is the heated up interest in the Two-Child-Policy from various quarters outside the Parliament. In a span of two years, five-plus PILs (4)have been filed in the Supreme Court seeking a directive to the Centre to enforce population control through a punitive Two-Child-Policy. The Court, however, dismissed all the PILs.

Unlike all the past moves to push the Two-Child-Policy, this recent 2020 bill garnered no media attention whatsoever. One can say the introduction of this bill went off the media radar. If this bill becomes an Act it will be the unprecedented law in India that will mete out punishments for having more than two children. It can bring serious setbacks to the sexual & reproductive health and rights of women, especially those from marginalized and poor communities. 

India being a signatory to the Programme of Actions of the International Conference on Population and Development (ICPD) 1994, cannot enforce a law that prevents a couple or an individual to decide freely and responsibly the number and spacing of their children. Post ICPD 1994, India’s National Population Policy had incorporated the PoA and stated its commitment towards “voluntary and informed choice and consent of citizens while availing reproductive healthcare services and continuation of the target – free approach in administering family planning services.”  However, with the turn of events happening towards the Two-Child-Policy, it seems that India will flout the PoA of ICPD (1994) if the bill becomes a law. 

Sources:

1^ “125 MPs appeal to President Ram Nath Kovind, demand strict two-child law; Opposition suspects ‘agenda’.” Times Now, 13 Aug 2018, https://www.timesnownews.com/india/article/population-in-india-125-mps-president-ram-nath-kovind-two-child-law-bjp-congress-explosion-2-child-law-petition/269006

2^ “125 MPs Petition President, Who Has No Role in Public Policy, to Implement Two-Child Norm.” The Wire, 21 Aug 2018, https://thewire.in/government/parliamentarians-president-petition-two-child-norm

3^ “Proposed two-child policy is against human rights.” Population Foundation of India, 31 Aug 2018, https://www.populationfoundation.in/NewsEvents/view/18/106

4^ “Fresh plea in SC on population control.” The Times of India, 21 Feb 2018, https://timesofindia.indiatimes.com/india/fresh-plea-in-sc-on-population-control/articleshow/63018969.cms

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Dr Nishitha Aysha Ashraf is Programme Associate for SAAF Project at 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.

Population is Exploding? Punishment Works!

In the last few decades when movies ‘Yours, Mine and Ours’’, ‘Khatta Meetha’ and shows like ‘Hum Paanch’  played out in cinemas and TVs, the amused viewers lived through the ups and downs of the reel families in laughter, joy, tears and sighs. Maybe we must have pontificated a bit on the cost and stress of running large families then. But surely we did not sound the death knell for the environment, employment and equilibrium while we enjoyed these feel-good movies. However, now with the Two-Child Policy bill on population, we might want to pooh pooh these movies and shows. Well, will we?

The chupke chupke (hush hush) act: 

The first week of February saw the Constitution (Amendment) Bill 2020 being introduced as a private member bill in the Rajya Sabha. There was not much fuss or attention. One can say it went unnoticed in the public like a hush-hush matter. If the bill ever becomes an Act, it will be the unprecedented law in India to punish families for having more than two children.  

The bill proposes that “there is also a need to encourage the people to keep small family by offering tax concessions, priority in social benefit schemes and school admissions etc. and at the same time discourage them from producing more children by withdrawing tax concessions, imposing heavy taxes and by making other punitive provisions for violations.” 

Population explosion, when? Now! Before implosion!

India currently stands at rank 2 in the global list of countries by population (1). China is first and the USA is third. With the list or without the list there is always the common comment that India is overpopulated, too crowded and “certain” religious communities are breeding as if procreation seems to be their main recreation. And when leaders, be it political or religious, continue to stress that India indeed is overpopulated, it does not need much persuasion for most Indians to fervently agree with them. But the critical questioning and critical dissection we need to do here is: is India really overpopulated? Is the Two-Child Policy needed to address the overpopulation?

Facts met myths and burst its bubbles:

Total Fertility Rate (TFR) is the rooting word to understand overpopulation and under population. TFR is the average number of children which a woman will have in her childbearing years (age 15 to age 49) according to the current birth trends. A population in an area is considered stable when the TFR is 2.1 such that no immigration or emigration has happened. The latest data shows us that most of the states in India have a TFR below 2.1 and only a few states are still above 2.1 TFR. Also, India will have an end to population growth (2) after going through ‘population momentum’ (3) following which there will be a ‘peak child’ and later ‘peak population’. So why this Kolaveri da on India being overpopulated? 

China, One-Child Policy and lessons: 

Population control and country’s development came together and weaved dreams of a better future for everyone who looked at China and wah wahed at their One-Child Policy. As China grew into one of the largest economies in the world, wielding a forceful control on her population, everyone had songs of praise for the One-Child Policy.  However, it took China 36 years to see the far-reaching consequences of the policy. 

Under population is a grave concern in China now where a high percentage of the population is elderly and non-working. The state uses its funds to give pensions while the state is having a shrinking working population. Also, the family structure takes an immense toll on the individuals, an effect appropriately termed as 4:2:1 wherein an individual has to take care of his/her parents as well as two sets of his/her grandparents in their old age. Thus the coinage 4 grandparents: 2 parents: 1 person. These family structures, where siblings are unheard of, thus cause immense financial and emotional pressure on the individual. China is a traditional society which still expects the adult children to provide for and support the ageing family members and have laws also to ensure the same. 

Patriarchal preference for a boy child added to the urgency of having that one child for a couple as a boy. Thus sex determination, even though is illegal, became rampant in China and so did sex-selective abortion. All these have resulted in a severely skewed gender ratio. 

China removed the One-Child Policy in 2015 and introduced the Two-Child Policy. However, not much hope is there for China to have a stable population even with the new policy (4).

Followers of religion & population control: wink wink?

Much anxiety looms in the country about Muslims causing the population explosion. Just going by the stereotypes of ‘hum do hamare panch’ (*us two ours five), people are quick to be stirred up by the populist view that Muslims will indeed overtake the Hindu population in the country and the WhatsApp University also does its share of spreading the “information”. What is conveniently left out is the fact that Muslims have been having a steep decline in their population growth. An article in a leading Indian newspaper (5) explains, “The 2011 Census puts the Muslim population at 17.22 crore or 14.22 per cent. The Hindu population grew in the decade of 1991-2011 at the rate of 1.55 per cent, while the Muslim population growth rate was 2.2 per cent. The fear about Hindus becoming a minority in India has the basis in this statistics. However, in the decade from 1991-2001, the growth rate of the Hindu population was 1.8 per cent and that of Muslims was 2.6 per cent. The decline in the growth rate for Hindus was 0.25 per cent and that for Muslims was 0.4 per cent. This is because of increasing literacy among all groups.” When it is easier to stir up the cauldron of hatred and fear to mobilize people why acknowledge facts that dispel the anxieties? 

Two-Child Policy: a peep into the future

Apart from the fact that policy is completely unnecessary, given how in the existing conditions India is heading to a stabilized population, enforcing this policy as a draconian law will push the poor people into a vicious cycle of poverty. Even with the law and dire consequences in place, there will be people who will have more than two children. While the rich can afford the consequences, will the poor be able to?  The limited access and knowledge to contraceptives and safe abortions, also the belief that having more children can ensure a better old age as their adult children will take care of them, will all make a poor man and a woman circumvent the policy and in all likelihood, they will have more than two children. With policy preventing them from availing benefits and schemes, they will be pushed further into poverty and thus they will end up in a vicious cycle from which they can never get out to have a better life. 

Guilty for pregnant: Blame anyone but partner and state

Women will walk on a tightrope if the Two-Child Policy becomes a law. In the currently existing conditions, it is the women who bear the brunt of (1) wanting to use contraceptives when her partner is against it (2) wanting to terminate an unwanted pregnancy when her partner is against it. Matters will be made all the grimmer for women with the Two-Child Policy as a law especially when they are victims of domestic violence. 

Contraceptives & Sterilization: We need to reflect on whether all women have access to contraceptives, whether these contraceptives are affordable and within their purchasing power, whether they are aware of all the choices they have in contraception and know how to make an informed choice on what suits them best, whether they have the negotiation power with their partners if they want their partner to wear a condom. We also need to reflect on the access and affordability they have for safe abortion, the robust public healthcare system and the legal system that will ensure that no women will be judged, discriminated or harassed for wanting to have a safe abortion. It is a valid fear that most women, especially from marginalized communities, will be forced to have sterilization after having two children. There is always the risk of giving selective information and insufficient support to enforce the law. 

Health: At the Hidden Pockets we have alarmingly seen an increase in the careless consumption of emergency contraceptive pills, commonly called as I-Pill. Many young women have one pill every week and this can be hazardous to health in the long term as the hormone balance will go for a toss and body consequently will have its reactions. Most of these women have confided to us that their partners refuse to use condoms as it interferes with pleasure. The onus for prevention of pregnancy thus falls on the women. When access and availability of oral contraceptive pills are a challenge, so also maintaining and completing the drug cycle, then emergency contraceptive pills become the quick fix.

Same story again and again:

Since decades experts have been shouting themselves hoarse that socio-economic conditions play an important role in population control. It has been ascertained census after census, how education and healthcare (6) are the factors that contribute significantly to help people decide, out of their own volition, that having a small family is indeed a good choice. What is highly problematic is the policy’s enthusiasm to make sweeping statements on the population without making any provisions to identify challenges in education and healthcare across the country and address them. Nor are there sincere efforts to address the lack of awareness on sexual & reproductive health and rights.  Experts always vouch that it is the development that can be the ultimate tool for population control and not punitive measures. We need to steer our policies towards those directions. Perhaps then we will be able to win again the nostalgia for those aforesaid movies. 

Sources:

1^ “2019 Revision of World Population Prospects.” United Nations Population Division, https://population.un.org/wpp/

2^ Ritchie, Hannah. “India’s population growth will come to an end: the number of children has already peaked.” Our World in Data, 15 January 2019, https://ourworldindata.org/indias-population-growth-will-come-to-an-end

3^ “The Inevitable Fill-Up.” Gapminder, 18 April 2018, https://www.gapminder.org/topics/population/fill-up/

4^ Kuo, Lily and Wang, Xueying. “Can China recover from its disastrous one-child policy?” The Guardian International Edition, 2 March 2019, https://www.theguardian.com/world/2019/mar/02/china-population-control-two-child-policy

5^Neelakantan, Anand. “The demographic change hoax.” The New Indian Express, 19 January 2020, https://www.newindianexpress.com/magazine/voices/2020/jan/19/the-demographic-change-hoax-2090213.html

6^Tripathi, Rahul. “Literacy leaves its mark as fertility rate goes south.” The Economic Times, 15 July 2019, https://economictimes.indiatimes.com/news/politics-and-nation/literacy-leaves-its-mark-as-fertility-rate-goes-south/articleshow/70220785.cms?from=mdr

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Dr Nishitha Aysha Ashraf is Programme Associate for SAAF Project at 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.

Condoms: Are they adolescent-friendly under Indian law?

A country’s laws regarding sex, sexual orientation, sexual consent, sexual and reproductive health, access to abortion services and access to different types of contraceptives can often become autonomy-snatchers in the name of protecting children and adolescents.

Even though Indian law does not explicitly prescribe any minimum age for accessing or buying condoms, there are indirect legal barriers which might make condoms less accessible for people belonging to a certain age group. Additionally, social and cultural mentalities also make the practice of accessing condoms difficult and stressful, so much so that those affected by these often indulge in unsafe sexual activities at the cost of their physical wellbeing. 

As per the Population Council’s 2016 report, out of the 10,400 adolescents who were part of the survey from Bihar, 14.1% of unmarried boys and 6.3% of unmarried girls had engaged in sexual activity. Out of these, 28.5% girls and 22% boys had had sex before they were 15 years old. Further, condoms were regularly used only by 20.3% of unmarried boys and 8.2% of unmarried girls. The same report also revealed that adolescents, 17.2% of adolescent boys and 6.2% of adolescent girls, in Uttar Pradesh are also sexually active (1).

Age of consent 

In India, the legal age of consent is 18 years. This implies that anyone who engages in sexual intercourse before they are 18 years old is doing something that the law does not permit. This legal nuance can create barriers to access. Many of the adolescents who want to engage in sexual activities but are less than 18 years of age might feel intimidated by the fact that they cannot legally consent to sexual activities that they willfully wish to engage in.

While this legal barrier may stop some from having sex until they are 18, it will force many others to have unsafe sex. They might be afraid to go to a pharmacy or other stores selling condoms for a lack of certainty as to whether the pharmacist or shop-owner would sell the condoms to them. Often, the pharmacist or shop-owner might try to estimate the age of those who come to purchase condoms and if they feel, as would be the case with many people below the age of 18, that the person is a ‘child’ (WHO defines a child as any person less than 18 years old), they might refuse to sell condoms to them. 

Does the law interfere with our sexual and reproductive rights?

Although access to contraception (and to safe sex) is a basic sexual and reproductive right, our legal framework on consensual and non-consensual sex creates problems in ensuring that this right is available to people of all ages. Even though the law does not see those below 18 as capable of consenting to sexual activity, many adolescents, particularly those between 16-17 years of age, are sexually active (1).

Given that India has the largest number of adolescents in the world (2) this puts a large number of people at the risk of getting Sexually Transmitted Infections (STIs) and a large number of girls at the risk of having unwanted pregnancies and unsafe abortions.   

Law – a mirror of social and cultural beliefs?

The attitudes of healthcare providers who sell condoms might be influenced by long-standing social norms and cultural beliefs. Although we have come a long way in destigmatizing pre-marital sex, we still have the limited perceptions that sex before people enter adulthood, and sexual experiences which are not to procreate, are reserved only for adults and/or married couples.

The sexual and reproductive health of adolescents below the age of 18 thus takes a backseat. People who can make contraceptives such as condoms easily available to adolescents almost always have judgmental attitudes.  Legal barriers like the minimum age for consent could be reinforced by such social and cultural mindsets. Ultimately, several of those below the age of 18 will still have sex but would be discouraged from buying condoms for a safe sexual experience. 

Public Health Programmes to improve access to condoms 

In India, the National Aids Control Programme(NACP) which is run by the National Aids Control Organization(NACO), a division of the Ministry of Health and Family Welfare, ended its phase IV in March, 2020. The programme aims to reduce and prevent the incidence of HIV transmission in the country.

As a part of its Targeted Interventions(TIs) among those who have a high risk of acquiring HIV, it focuses on “the promotion and provision of condoms to HRG(High Risk Groups) to promote their use in each sexual encounter”. Under its strategy of condom promotion, focus is on increasing demand and availability of condoms . Free condoms, called Nirodh, are procured by the Ministry and then distributed by NACO through NGOs, Anti-Retroviral Treatment(ART) centres and Integrated Counselling and Testing Centres(ICTC).

Condoms are also distributed through Social Marketing Organizations which use promotional campaigns to sell condoms at subsidized prices. Under the NACP, condoms are also marketed as private brands and sold commercially at full prices. 

The Reproductive, Maternal, Newborn Child plus Adolescent Health (RMNCH+A) programme focuses on improving maternal and child health by using a holistic approach and covering health throughout the lifecycle. Under its family planning services, free condoms are available at government health centres and are also distributed in rural areas by Accredited Social Health Activists(ASHAs). 

Shifting approaches:

We need to adopt a balanced approach when it comes to legislation that might directly or indirectly affect young people’s access to contraceptives such as condoms. Although the age of consent in India is set at 18 years with an alleged view to protect children and teenagers from sexual exploitation and abuse, such a blanket law takes away their sexual and reproductive rights. The age of consent must not be too high since that leads to many below the age of consent to have unsafe sex or to not engage in sexual exploration at all. It should also not be too low because that increases the risk of children and young people being subjected to sexual abuse and thus other physical, emotional and social complications can arise from such abuse.

Increased access to condoms:

Condoms can be made to be more within the reach of those below 18 years of age through the setting up of  Adolescent Friendly Health Clinics (AFHCs) by health professionals who are part of the private medical factor. These clinics would have a role similar to that of the AFHCs that are set up as a part of the Rashtriya Kishor Swasthya Karyakram (RKSK), a programme led by the Ministry of Health and Family Welfare to improve the health of India’s adolescents. Since these would not be controlled by the Government, they would have the autonomy needed to provide effective and non-judgmental sexual and reproductive health services. More adolescents would be able to go to these clinics and get contraceptives like condoms and the clinics would maintain their confidentiality.

Sexuality education:

No matter where we stand as a society in terms of openness towards and acceptance of sex among adolescents, meaningful sex education in schools will always be of paramount importance. This education should be far from instructing those between 16-18 years of age to not have sex or to not engage in any kind of sexual activity. Rather, it should educate them on the ways in which they can have safe sex and why safe sex is important for their sexual and reproductive health.

Role of social media:

To be able to cultivate healthier attitudes towards adolescents having sex, more of us need to come out on social media and talk about why it is important to put an end to the ways in which society often tries to portray sex as wrong. However, in these present times when pedophiles are lurking in cyberspaces to groom minors, it is highly important that minors are also given the education to discern sexual exploitation as well.  Social media is a powerful tool that can be harnessed well to inform, educate and empower the teenagers such that they can make informed choices about their sexual activity. This way more teenagers might be encouraged to overcome any hesitation or fear and buy condoms. Importantly, more and more healthcare providers (pharmacists, doctors at govt. health centres) would develop friendly and non-judgmental attitudes towards teenagers having sex.

Conclusion

Although there are public health programmes in place to make condoms increasingly accessible to the people in this country, legal interventions in the form of a minimum age for consent to sexual activity might make many adolescents below the age of 18 reluctant to buy condoms before having sex. Further, for those who do go to buy condoms, service providers might not sell condoms to them based on their age. The scary part is that all this would not stop those below 18 years of age from having sex. It would only make many of them indulge in unsafe sex. 

About the Author: Navya Dawar

She is a second-year student pursuing BBA LLB Honours at Jindal Global Law School, Sonipat, Haryana. She aspires to, one day, be a part of something that helps people believe in themselves and cherish themselves for who they are while simultaneously becoming aware of their own potential for personal growth and exploiting this potential to become better versions of themselves. She loves drinking tea, playing tennis and is fond of working out. She likes to sing and read and aspires to go on long-distance solo hikes at some point in the future.

Sources:

1^ Population Council. “UDAYA-Understanding the lives of adolescents and young adults:Bihar Factsheet 2016.” popcouncil.org, https://www.popcouncil.org/uploads/pdfs/2017PGY_UDAYA-BiharFactsheet.pdf

2^ UNICEF. “Adolescent development and participation.” unicef.org, 3 June 2019. www.unicef.org/india/what-we-do/adolescent-development-participation

Abortion in the Steel City Ballari: Part 1

Ballari is not a word that rings a bell for someone new to Karnataka. For the uninitiated, the word can even morph into Bel Air, when pronounced with a rolling tongue and playfulness! Ballari and Bel-Air, however, are two worlds apart. Karnataka, a state in south India, has its trump card districts like Bangalore and Mysore which win the hearts of people as it offers them hopes and dreams to build a better future. Ballari, for many, remains that place identified as “rural”, “village”, “countryside”. The stamp of Steel City on Ballari does little to make the place a sought after one. 

Introduction to the SAAF project: 

As part of the SAAF (Safe Abortion Action Fund) project “Abortion is Care”, we charted out a plan to travel to Ballari, assess and map out service providers who can give safe and legal termination of pregnancy in accordance with the guidelines of the Medical Termination of Pregnancy Act, 1971. What should otherwise have been meticulous fieldwork of weeks, ended up getting shrunk to a series of telephone calls to service providers during the COVID-19 pandemic. We had to adapt as there were no other means to reach Ballari. 

Can the internet help me find an abortion?

For Google and smartphone-driven youth, the internet is the first place to go when in need of information. Usually, a quick search can unfold pages after pages of information on anything under the sun. However, when it comes to information on accessing medical termination of pregnancy near your place, the internet does not have it all, especially for a place like Ballari. Whatever combination of words one uses – Ballari – Abortion – MTP, the net gives either a list of gynaecologists in Ballari or a hospital/ nursing homes where gynaecologists/ or department of gynaecology are present. Questions remain: “how many youths will pluck courage and call/ go to these people/places and risk getting insulted/humiliated for asking about abortion/getting an abortion, especially if they are unmarried women? And how much of the lists on the net are accurate about providing abortion?”

Hear hear the doctors:

Calls were made to the hospitals and nursing homes to enquire about MTP. Most often, the staff who handled the helpdesk/ enquiry/ reception were not equipped with necessary information on MTP and were quick to dismiss further questions with a reply “you can come here and get the consultation done. We don’t know much about MTP, the doctor can tell you.” Some offered the contact number of the doctors to take the conversation further while a few maintained that they cannot share the numbers due to the organization’s policy. However, the latter offered to connect the doctor through the hospital landline.

Calling the doctors was a hit or miss as very often they would either be in O.T or away for breaks. This was especially the case when the doctors were connected via the organization’s phone line. One had no option but to wait and call again later or on another day. We, at Collective, were left wondering how a young woman in distress about MTP, will handle these waiting periods, just to have a few words with the doctor! When we did get the “golden moments” to talk to the doctor, many took out time to tell us more about what was happening in Ballari and many others abruptly ended the call stating that they do not conduct MTP for single women.

The charm and pain of naivety: 

Doctor A was very empathetic to the issues single women are facing to access safe and legal abortion in Ballari. She said that she can provide MMA under 7 weeks of gestation for single women. However, for above 7 weeks, she will not be able to help as the hospital she works for, will not want to get involved in any possible complications that can arise post-termination, especially if it is a surgical termination. She explained that a single woman most often does not have legally authorized signatories for conducting the procedure nor does she have people who can take up the responsibilities in the wake of any procedure going not as planned and these put the hospital in a tough spot. 

Doctor A shared about her years at a government facility where she had seen cases of single women who came in past 12 weeks of gestation. She said it was saddening to hear the stories of these women who had no idea about anything that has to do with sex or pregnancy and are put in a position where they now need to terminate the pregnancy. By the time they seek medical help, the pregnancy has advanced and many complications could have been avoided, had they approached the doctor at an earlier gestation period. She added that most of the cases she has seen at the government hospital, filled her up with the need to go to the communities and educate them about safe sex, the timeliness in accessing the termination and the importance of taking help from doctors and staying away from quacks. 

Doctor A, however, confessed that her position as a gynaecologist in a government setting did not give her the time and the role to reach out to the community for the same. She strongly feels that if public health groups, NGOs are to take up this role, it will do immense good to the community. She highlighted that most often everyone has this notion that villagers are naive and conservative, and that they will not receive well all these information & awareness programms on safe sex, contraceptives, pregnancy and termination. But, from her experience as a gynaecologist, she believes that they are far more receptive to these information and earnestly want interventions that will help them. 

Mushrooming nursing homes:

Doctor B who had previously worked at the only tertiary government hospital in Ballari, VIMS (Vijayanagar Institute of Medical Sciences), and now working in a private nursing home as a consultant, shed some light on what was happening in Ballari when it comes to abortion. She said that a lot of people reach out to government hospital for an abortion, given how affordable it is there. However, because of the patient load and the ensuing delay in getting a consultation, many abandon the waiting queue and resort to nursing homes to get a faster resolution. She pointed out that many nursing homes have been mushrooming in Ballari in the last decade, and most of them offer termination services. According to her, what is worrisome is that many of these nursing homes are not authorized to conduct MTP, and people are not aware of that. Doctors too partake in this and provide MTP when they are not qualified to do so. When asked about whether she can provide MTP, she said that she is only a consultant in X nursing home and that nursing home conducts only deliveries. So far, they have not provided any MTP to any women, be they single or married. She, however, suggested a few leading nursing homes in Ballari where MTP is provided but added that she is unsure whether they are single women friendly or not. 

Yes and No to abortion:

Doctor C stated as a matter of fact that she discourages abortion even in married couples. She opined that couples should proceed with pregnancy to full term and counsel for the same to any couple who approaches her for termination. 

Doctor D was not out rightly against abortion. However, she conducted abortion only for those married couples who are carrying pregnancy with foetal abnormalities that warranted abortion. 

Legal tangles in abortion:

Doctor E revealed to us that the nursing home she worked for, had a case last year wherein a minor girl had to get termination and the POCSO investigation had to be initiated. She said that currently, the nursing home is not providing termination for single women. She ascribed this change to the legal entanglement that doctors can get dragged into, the numerous court appearing for depositions, the unending dramas which the parents of a single woman can stir up when they come to know about the termination, and in worse cases, they malign the doctors’ reputation too. According to her, many doctors (including herself), even though are sympathetic to the single women’s need for abortion, are wary of taking up the issue because of the possibilities of compounded factors of medico-legal cases. She confided that a few of her friends from the medical fraternity in Ballari were embroiled in such cases and thus decided to stop providing termination for single women. She noted that many senior doctors in Ballari are adept at navigating all these red flags and have been helping single women in Ballari get a termination. However, in light of the pandemic and them being in the high risk group due to their age, they have suspended all their practice for the time being. 

Ballari in news:

We were in for a surprise when our preliminary internet search on Ballari turned up news reports about Ballari and abortion. According to the Times of India report dated 21 December 2001 ( that is almost two decades ago!) Ballari was chosen for the Safe Abortion Project. Under this Safe Abortion Project, Karnataka had three districts viz Ballari, Raichur and Bijapur. 

We also found news wherein the Supreme Court stayed the arrest of a Ballari doctor accused of terminating the pregnancy of an alleged rape victim. We realized doctors have it tough in Ballari when we found news of a husband pressing charges against his wife and the doctor for terminating a pregnancy without his permission. We were again left wondering, how cases like these can have its own ramifications within the medico fraternity in Ballari who provide termination. 

Fieldwork amidst the pandemic:

As the weeks go by and we all are starting to let it sink in: the virus is here to stay, we also are looking forward to having safe access to Ballari. Our preliminary search, so far, has given us the narratives from doctors and news from the net. We are eager to meet the communities and youth of Ballari and hear what they have to say when it comes to accessing sexual and reproductive health services. We are sure that having the youth with us will help us see Ballari through another lens. 

Writer: 

Dr. Nishitha Aysha Ashraf is Programme Associate for SAAF Project at 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.

Child Marriage and Teenage Pregnancy

Playing with dolls is something most of us have done growing up. Child marriage was nowhere in our minds. We revelled in our games: to set up our own world of imagination and to have our dolls play the characters we want to. We name the dolls, we make them have doll marriages, have them set up their homes, make doll wife cook food in their doll kitchens, have her sweep and clean the dollhouses, send the husband doll away for work and even add doll babies for wife-husband doll parents! When we hit our midteens, we would have moved on from dolls to vividly conjure up a bright future for us, with us being the leading character in all our romantic movie plots: the imagination propelled us up with hope and anticipation for the future. Little did we know the realities of adult life and we naively believed in the everlasting happiness of marital bliss. We were fortunate enough to get our time to grow into adults and then enter the adult world of responsibilities and realities. We put behind our dolls and teenage imaginations. However, this COVID-19 lockdown crisis that we are living through, is making many boys and girls give up their childhood way before its time and sadly amidst the fear and panic about the virus, many of us are not seeing it. 

Child marriage has been steadily increasing during the lockdown and this is extremely worrisome. Even in pre lockdown years, the number of child marriages in India was problematic. Girls Not Brides states that 27% of girls in India are married before their 18th birthday and 7% are married before the age of 15 and according to UNICEF India has the highest absolute number of child brides in the world – 15,509,000. Now with the lockdown in place, the numbers are expected to shoot up. 

Childmarriage: livelihood and security

As COVID-19 lockdown continue to increase the uncertainties, many are losing their livelihood. People are staring at a blank future and don’t know how to make sense out of a crisis when they don’t have any money coming in. As days go by, and whatever little savings are getting fast depleted in procuring food and essentials, they fear about the future when hunger will overpower them to do things that they would not do otherwise. 

John Roberts, Programme Head, Southern Region, C.R.Y (Child Rights and You) says, “In the lockdown, the livelihood scenario is hit so badly. There is greater stress, indebtedness and desperation. Famish and poverty have become worse. There is a huge connect between livelihood stress and pushing children into marriage.” 

Vasudev Sharma, Executive Director, CRT-Child Rights Trust, says, “Economic factors are the primary reason for most of the child marriages. I see child marriages at two levels – one, families want free labour (younger the girl, more obedient and subservient she is); second, the son of the family will come back to the house every evening (and will not go in search of love outside).”

Vasudev adds that there may be some social pressure that may operate on the families, wherein relatives, matchmakers and neighbours may motivate/persuade the parents with adolescent girls to marry her off at the earliest. John also notes how patriarchy, culture all have a role in fuelling child marriage, especially during a crisis. 

Child marriage and shut schools

When schools were functional, it kept the children in schools. Most parents and communities would not dare to get the children married, as it would bring in trouble for them with the alert and responsible school authorities reporting the plans or the marriage itself to the child protection services. However, with the lockdown in place and schools shut, many contriving parents and communities are making the most out of it. Also, with uncertainties about livelihood looming large for parents, many are forced to go back to the relatively secure and comfortable lives of their native place and communities living there. As parents move, so will their children move with them. Many children who otherwise would have been safer and secure in schools and hostels are now thus put in a situation where their rights as children will have no value whatsoever, especially when parents and communities do not ensure children’s security.  

Vasudev, says, “As we see and understand that there is a long holiday (till September schools would not start). This long period may work against the interest of the children, particularly girl children – pushing them into marriage or child labour or such victims of crimes.” He also adds, “When some of the families have to return to their workplaces, maybe in urban areas, they may consider the adolescent girls as a burden and may think of getting them married.”

Child marriage, SRHR during lockdown:

Every phase of the lockdown has posed huge challenges to ensure sexual and reproductive health and services are accessible and available to all. Unmarried girls, especially, were hit hard when they discovered that they are pregnant. When living with parents and having neither cultural sanctions to be an unwed mother nor get a safe medical termination of pregnancy, they took up the “only option” put forward or rather forced upon them by their parents viz a marriage, even though it meant that they are marrying as minors.

For the already married minor girls, the lockdown not only pushed them into a hurried marriage but is also pushing them into early pregnancy. They have little choices on contraception and abortion services during the lockdown. They have limited access to transport and even if they do reach the places they are turned away by the service providers who are working in limited capacities amidst the fear of asymptomatic virus carriers. It is anticipated that this lockdown will have a long term impact on minors due to the unwanted and unintended pregnancies. The teenage girls are being forced to be mothers when they are not ready for it. 

John says, “evidence gathering studies which we, at CRY, have conducted in the past in Tamil Nadu and Karnataka have shown us that teenage pregnancies occur. Young girls who are forcefully married end up in a miserable marriage. Spousal abuse happens, husband abandons wife or husband and wife live separately. Early and child marriages ruin the lives of girls.”

Report and Rescue:

The lockdown has posed challenges to the prevention of child marriages. With the initial weeks having no clarity from the government about the dos and dont’s of lockdown, many parents took advantage of the absence of the Child Marriage Protection Officers. Though some instances were reported to the ChildLine 1098 and the police, most of the time such child marriages have gone unnoticed and unreported before the marriage. With the breakdown of civil registration systems at many places during the lockdown, many child marriages have escaped the scrutiny of the law and its subsequent course. Vasudev explains, “You get to know about a large number of child marriages only when the daughter-in-law arrives at the husband’s house and the worse situation when the below 18 daughters-in-law reaches the PHC and the AWC.” 

To prevent and to protect:

Vasudev suggests immediate measures that need to be done to prevent child marriages, “The urgent need is that the local Govt (Grama Panchayats) take a census/count of all the children in their vicinity and jurisdiction and particularly adolescent girls from a protection perspective.”  He explains that though the local school or AWC may have the count of the children who were otherwise in the same village all the while, the count of the new arrivals (migrants who have returned, girls who have come back from hostels and such arrangements) need to be recorded. This can help in assessing the needs of the children during the lockdown – their nutrition, medical help, protection.

He stresses on the importance of conducting intensive public education/warning about dire action if any child marriages are attempted and thinks it is highly needed to educate all girls and boys, adolescent boys and men about the legal actions that they have to face if they attempt child marriages and child abuse. And to respond according to the COVID-19 times, he suggests considering any child abuse in the form of child marriage or sexual abuse under the Disaster Management Act.

John draws attention to the need for more inclusive packages from the government that keeps the children also as a major focus. He says that if one looks at the budget allocation or resource allocation so far, and also especially of the lockdown, it appears that children do not exist at all. “There is very little from a child’s perspective.” With schools closed and uncertainties looming about when the reopening shall be, many children are losing out on their mid-day meals that kept their tummies full and hunger at bay. Anganwadis which used to be the go-to place for many adolescents for nutrition and supplements now stays shut at the blank faces of these youngsters. And so far, it appears that the government has not opened its eyes to the perils of children during this lockdown. “ As long as parents are hungry, as long as children are hungry, there will be always the desperation. The hunger will push people into all kinds of other situations. The state must look into far more comprehensive responses, especially from the point of view of the poor.” 

Experts suggest that the state and NGOs need to collaborate and work together to ensure the safety, nutrition, health, education of the children. Especially during this pandemic, it is imperative that the needs of the children are met appropriately, such that the trauma and stress of children too find a place in the discourse to solutions in the times of lockdown. Many children are not aware of the “whys” of the lockdown. They are silent spectators to this unprecedented time, unable to comprehend the tectonic shifts that are happening to their little world they are in. While urban and rural boys and girls may experience lockdown differently, one thing is sure that they are all suffering in their own worlds. 

For the young readers benefit, who are not well versed with the government’s role and mechanisms in place to report and prevent child marriage, Vasudev Sharma, Executive Director, CRT-Child Rights Trust, elaborates on how the system works:

“The Prohibition of Child Marriages Act (PCMA) 2006 empowers everyone to complain if they come to know about any possible child marriages. The local authorities – School Head Masters, ANM, Grama Panchayat PDOs, Supervisors of the AWCs are the CMPOs (Child Marriage Prohibition Officers). All police sub-inspectors and above rank are also CMPOs. There are hundreds of other officers at taluk and district who have the authority to prevent and file cases if they get to know about child marriages.

One can reach out to police or ChldLine 1098 about the possible child marriages (anybody, adult or children – the victim or any child). All are assured of maintaining anonymity. Their identity will not be revealed.

But we urge that the information should reach the authority at the earliest. Don’t wait for the marriage day. We are not supermen or women to appear in a jiffy to stop the marriage as it happens in Indian films! We too require time to prepare, plan and arrive at the village to take up action.

The ChildLine 1098 representatives or police or DCPU would visit the site on receipt of the information and conduct their own inquiry and take necessary measures.

If the child requires to be rescued from the location, she would be provided shelter under the state care after producing the child before the Child Welfare Committee. The girl’s education would not be affected and she can always go back to her family once the situation subsides.  The family would be counselled to prevent child marriages and the authorities may even file a case against the perpetrators.

If the marriage is performed, filing the case becomes inevitable under various sections – PCMA, IPC and even as per the POCSO.

If there is any adult hand in instigating the girl to elope, that will be considered as kidnap and further measures will be taken along with POCSO and IPC provisions.”

Dr Nishitha Aysha Ashraf is Programme Associate for SAAF Project at 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.

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Medical Abortion: Nurses have a Say?

Have you heard the Beatles song “Help?” or  Do you remember that song? Ever thought it along the lines of people in need for abortion and nurses?

“Help, I need somebody.

Help, not just anybody,

Help, you know  I need someone, help.

When I was younger, so much younger than today

I never needed anybody’s help in anyway

But now these days are gone, I am not so self assured

Now I find I have changed my mind and opened up the doors.

Help me if you can, I am feeling down.

And I do appreciate you being around.

Help me, get my feet back on the ground

Won’t you please, please help me.”

What would otherwise be a loved up song from the Beatles, takes on a whole new persona with innumerable interpretations during this lockdown due to COVID-19 pandemic.  For us, at Hidden Pockets, this song ran deep as the Careline services continued to grapple with the increasing distressed calls from young people who feared that they might be pregnant and were helpless about getting an abortion.

The lockdown posed a huge set of challenges to make sure abortion – an essential service declared by the Government of India in phase 2 of lockdown – is accessible and legally available for those in need. Discussions were unfolding to broaden the scope of telemedicineto include medical abortion. It is in these crisis times that all doors need to be knocked upon to make sure women have access to safe and legal abortion. One such door is the policy change to have nurses who are highly qualified and trained to be eligible to administer medical abortion pills for the pregnant persons, a possibility that was nipped in the bud in the latest MTP Amendment Bill 2020. 

The global Indian nurse

Antonia Pushpraj, a Senior Nurse Strategist with 28 plus years of experience in nursing profession said, “The entire world looks up to Indian nursing and India itself should have trust in the capabilities of the nursing professionals today. However, this is not the case and it is time that the medical professionals put the capabilities of nursing professionals to test and trust them.”

Experts say professional nurses undergo rigorous training during their years as students. While the initial years are rooted in basics such as anatomy and physiology, the latter years have diverse subjects such as gynaecology, paediatrics and more. For GNM and BSc nursing students an entire year is dedicated to maternal and child health according to the curriculum drafted by the Indian Nursing Council. In addition to this, the Indian curriculum incorporates other disciplines such as sociology which makes the nurses of India have multidisciplinary training.

“After BSc nursing, many people choose to specialize in MSc OBG. Some even go on to do their M Phils, doctoral and even post-doctoral degrees. We have a highly trained group of professional nurses in our country, who in turn can train and mentor the younger generation, ” said Antonia.

Nurses and Abortion

Many are quick to jump the gun and say a loud no at the possibility of nurses handling the medical termination of pregnancy. What is lacking in these dismissals is the patience to understand how a nurse is also as proficient as a doctor in administering and managing medical termination of pregnancy and what exactly is medical termination of pregnancy. Very often, people without understanding either are too quick to have graphic images of bleeding person, surgical tools and a foetus when they hear abortion. 

Dr Alka Barua (Abortion Theme Lead at CommonHealth) who is a medical doctor with more than 35 plus years of experience working for SRHR of women said, “ global studies have shown that nurses are capable enough to administer medical abortion pills and even WHOhas laid down such a recommendation based on these studies.” She elaborated that medical abortion is not the same as surgical abortion. In medical abortion when nurses administer pills, they are not intervening internally with the person’s body, unlike a surgical abortion. 

However, many doctors in India are not comfortable with the possibility of nurses permitted to administer the pills. One of the main reasons given by them is that in the event of ectopic pregnancy and a pregnant person takes the pill, it can lead to severe complications and that nurses are not skilled enough to detect an ectopic pregnancy. They also cite reasons such as that nurses can be careless with the pills and give the wrong drugs or wrong dosage or even give it in the wrong week of gestation. 

Anubha Rastogi, Mumbai based independent lawyer said, “ According to the existing laws under MTP Act, 1971 it is illegal for a nurse to conduct medical abortion. However, it is highly desirable to include nurses.” She elaborated that when the work around the MTP Amendment Bill 2020 was taking place, one of the key recommendations/ demands which advocacy groups had circulated to the Parliamentarians (both the Lokh Sabha and the Rajya Sabha) was to expand the service provider base for safe and legal abortions and include nurses as well. However, there was a strong backlash from medical bodies and OB-GYN bodies against such an inclusion. These bodies maintain the stand that medical abortion pills can be given only by doctors and nurses do not have the expertise to handle the complications that can arise.

Paisa, Paisa, Paisa

There is a widespread belief among many advocacy groups that doctors are indulging in a power game when it comes to abortion. They allege that doctors know a lot of money is involved in the termination of pregnancy and hence they would not want to let go of the commercial benefits that they can reap out of abortion services. This is one of the many reasons that doctors are reluctant to share their “power” of being the authorized abortion providers and thus monopolize the need by charging a hefty fee.

 A confirmed source said that a few doctors go to such an extent that, what would otherwise have been a simple and easily affordable medical abortion, is intentionally delayed by citing different reasons so that the pregnancy enters a gestation period wherein medical termination will be risky and thus a surgical termination of pregnancy will only be the option for the person who needs an abortion. This, in turn, brings in more money, especially for the corporate hospitals as well as the doctors working in the private sector. It is said that a profit cut is made for every surgical abortion in these sectors. 

Another confirmed source said that the money-minting is not restricted to private doctors alone and that government doctors too are in the game. According to the source, many states allow government doctors to have a private practice. Some of these doctors get the training from government training sources/ organizations for abortions and then later they divert the cases that come to the government hospitals to their private clinics which makes it possible for them to charge a higher fee.

Power Play

Nurses said that the power games of doctors do not just end there but it translates to the working spaces as well. In spite of being highly qualified and trained, many nurses constantly face the humiliation of distrust from the doctors. Very often, their skills are questioned and rebuked by the doctors. It is a public secret amongst the medical fraternity that most doctors do not trust nurses. This, in turn, translates to distrust from the management. The nurses asked that if doctors do not trust them, then how will the management trust them, who will the management listen to: doctors or nurses? The hierarchies are very well defined and often professional camaraderies and support are missing.

Experts, however, highlighted the severe shortcomings that are plaguing are plaguing the nursing training since the last few decades. The fact that there has been a mushrooming of nursing colleges throughout the country which lacks connected practice areas/hospitals with enough patient inflow needed for the nurses to hone their clinical skills point to the larger problem at the higher levels of authority. They also said that many nursing homes employ people who have education, not beyond the tenth standard, and are given rudimentary training, the coveted uniform of nurses, and are made to work as “nurses” on a pittance as salary. All of these can contribute to questioning the expertise and proficiency of nurses in the public’s eye who are unaware of the larger story and what goes into the training of a professional nurse.

Digging Deeper

Educationists said any education and training need to be done along with the KAP model (Knowledge, Attitude and Practice), be it for the nurses or be it for the doctors. This is very important especially for abortion as nurses and doctors can be thorough with the textbook knowledge on abortion but severely fall short in good attitude and practice. With respect to abortion, which still continue to hold stigma, guilt, shame amongst the larger public, it is needed that both the nurses and doctors ought to leave behind their personal prejudices, beliefs, judgements once they dorn their professional attire and tend to the patients. And for the same, the curriculum needs to have modules on training the students. 

Antonia said, “empowerment of nurses is not fighting with doctors.” Pointing to the cacophony that exists between nurses and doctors, she noted that capacity building can only be achieved through trust. “If a nurse lacks confidence in spite of her high education, doctors can be a team player and help the nurse build her/his confidence and make her/him an expert. The doctor can supervise in the beginning and gradually step back once the nurse has gained the expertise.” 

Pharma Folks at Your Service

Dr Alka elaborated on the findings of a study conducted by the Guttmacher Institute, which stated close to three in four abortions in India are achieved using MMA drugs from chemists and informal vendors rather than from health facilities. She said, “the study has said it loud and clear that a huge proportion of women in India procure medical abortion pills from sources who are not trained nor authorized according to the MTP Act. This study itself should ring a warning bell to the government that the abortions services are not being met through private or public health facilities for whatever reasons and that in such a circumstance make amendments in the MTP Act to include more service providers like nurses who are trained well.”

Experts said that if nurses are given thorough training on dosage, the required patient counselling, how to look out for complications, the necessary follow-ups and reference, any day the person who needs abortion will be far safer in the nurses’ hands than in chemists’. They say the most common objection cited by doctors on ectopic pregnancy does not hold water as it is not very frequent and doctors themselves don’t often detect it. 

Doctors are almost always put on a pedestal by our society. It is time we stop having blinders and see the desperation in pregnant people to get an abortion. Perhaps it is time we also put nurses on a pedestal such that they too can help the person in need. Or better bring the doctor down from the pedestal and have both doctors and nurses do justice to their noble profession. After all, to call a profession noble, it surely has many added human values in it. It is time the pregnant person is treated with humanity- legally and safely- to get an abortion.  

Writer : 

Dr Nishitha Aysha Ashraf is Programme Associate for SAAF Project at 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.

Connect with us on our social media pages to get updated about Sexual and Reproductive Health and Rights.

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Telemedicine and Abortion: India says Yes or No?

COVID-19 has brought all of us to a standstill. It is highly unlikely that we no longer take things for granted after witnessing first hand how interconnected all our lives are. What would otherwise have been a skip, hop and jump to the pharmacy near our house to get, say a basic Paracetamol tablet, has now become desperate speed walks to all the pharmacies within 4 km radius of your house! We witness first hand, what it means when newspapers say supply chains have been affected and medicines are going out of stock. We may want to sigh, we may want to be angry at all those folks who made panic purchases earlier, who have hoarded their medicine cabinets and stayed safe in their houses with glee and satisfaction. In this case, can Telemedicine be an option to look at?

Now, what if you are to find out you are pregnant, or your partner is pregnant? What if you had not planned this pregnancy? What if this pregnancy is creating severe anxieties for you and/or for your partner given how the future looks very uncertain due to impending economic recession and thus makes you feel the pregnancy as unwanted? What if you are to find out you are pregnant while staying with your parents during this lockdown who have no clue that you are sexually active and surely will not receive well your discovery? What if this COVID-19 pandemic and the lockdown has severely restricted your access to safe abortion

India is now entering the fourth week of nationwide lockdown with 17 more days to go for the lockdown to end. Even though hospitals and pharmacies are essential services during this crisis, they are plagued with challenges. Many of the hospitals which are functional even during the lockdown, now have a dearth of Personal Protection Equipments (PPE). The staff are in the high-risk group of getting exposed to the virus and those hospitals where staff tested positive are shutting down their services. Pharmacies are facing supply chain hits and shortages of stock. Amidst all these, when you identify as one of those people mentioned in the above para, what are you to do next? 

India has a relatively liberal law on termination of pregnancy and much to the surprise/ ignorance/ confusion of many Indians: abortion is, in fact, legal in India, not as a byproduct of the liberal times, but as a legal right ensured by the Medical Termination of Pregnancy Act, 1971. Also, the recent amendments to the MTP Act 1971 passed in the Lok Sabha in March (just as the country was waking up to COVID-19 crisis), gave many the reasons to celebrate that India is moving towards more progressive abortion laws. However, there was dissonance from many quarters about the amendments being lopsided. Now, as we navigate through this lockdown, it is surprising that the necessity of timely and safe access to abortion has eluded the health sector amidst the pandemic panic and many experts and activist circles have overlooked the urgency for ensuring access to safe abortion during the lockdown. 

The lockdown is giving a tough time for scores of women to have access to safe abortions, especially for those women who do not have the convenience of distance and the privilege of a personal mode of transport. Even if they do reach the hospitals, abortion is still out of reach for them as abortions are elective procedures and most hospitals are now postponing abortions citing the risks of exposure to the virus. Almost all elective procedures including abortions are on halt at hospitals as it is highly likely to have patients who are asymptomatic and thus there can be contamination, posing a risk of infection to the hospital staff as well as the patients. 

While ‘stay home, stay safe’ is indeed the need of the hour to ‘break the chain’, many are pushing for telemedicine to address the health issues of the population such that neither the doctor nor the patient has a risk of getting exposed to the virus.  Recently the Ministry of Health and Family Welfare, Government of India issued guidelines for telemedicine practice which has solidified the acceptability of this new mode of medical intervention. These guidelines have now made it legalto practise telemedicine in a professional setting. The scope of telemedicine for Sexual and Reproductive Health and Rights (SRHR), especially for abortion, holds a lot of promise. However, there seems to be no specificity whatsoever about abortions, a much-needed service, in the existing guidelines.  

According to the experts, there is lack of clarity even though the Medical Council of India (MCI) released guidelines specifies what entails telemedicine in India, who can practice telemedicine and how e-prescriptions can be provided to clients. They explained that at present, the Government of India allows only over the counter medicines to be e-prescribed apart from some drugs like chloroquine in endemic areas while Schedule X drugs are strictly prohibited. They opined that they would discourage online prescriptions apart from what is included in list O (Over The Counter) in the telemedicine guidelines and firmly think that in any circumstances, medical abortion pill cannot be prescribed over telemedicine in India, not even during an epidemic.

Dr Ashok Kumar Devoor, Senior Gynaecologist and Advisor to Hidden Pockets Collective said, “Two important prerequisites of abortion are (1) clinical examination (2) confirmation by scanning. Scanning is very important as it helps to ascertain whether the foetus is growing within the uterus or outside the uterus, that is in the fallopian tube. Now, if one were to take medicines to abort the foetus, without knowing that foetus is outside the uterus, it can lead to serious consequences. The fallopian tube can rupture and the woman’s life will be at risk as it is a medical emergency and needs immediate surgical intervention. Hence scanning is a must to know whether the pregnancy is within the uterus.”

Specialists say that the termination of pregnancyup to 9 weeks is usually done through medicines given under medical supervision with follow up at hospitals and clinics. For pregnancy beyond 9 weeks and under 12 weeks, surgical termination of pregnancy is needed. 

Dr Shamala A. Dupte, Director Medical and PD- GCACI, Family Planning Association of India (FPAI) said, “ Access to safe abortions is a fundamental reproductive right. The mobility of staff and also the patients have been restricted during these lockdown times across the country. However, our clinical teams have braved all challenges to ensure that women continue to access these essential, time-sensitive services. We provided safe abortion services including pre and post-abortion counselling and contraception to over 200 women from 1st April to 12th April 2020.”

Countries like the UKhave already made it possible to have medical abortions within the safety of one’s own home during this pandemic. This is a temporary policy change and women need to follow a telephone or e- consultation with a doctor for abortion at home. 

Dr Ashok thinks that safe medical abortion through telemedicine is possible and much needed in India during the lockdown. However, he stressed that provisions need to be made such that if medicines are prescribed through telemedicine, it is done so only after scan results are obtained. Also, he highlighted the importance of having access to hospitals for those cases where there has been incomplete abortion. 

The possible manipulation of telemedicine for sex-selective abortion is real, especially in India where male child preference is high. However, experts said that it is the same as the one that would exist even in a clinical set up: a woman who already knows about the sex of the foetus through scanning can approach another doctor and request for an abortion in a clinical setup. 

Since the lockdown, Hidden Pockets Collective, the only real-time Careline service on sexual and reproductive health service across India, has been inundated with pleas for help from youngsters who fear that they are pregnant. What otherwise would usually be places where Hidden Pockets did not have any presence, places such as Kashmir, Nagaland, small pockets of Bihar – Uttar Pradesh – Telangana, are now emerging strongly towards Hidden Pockets during the lockdown. The SOS messages have moved beyond the metropolitan cities in the country. 

Aisha Lovely George, the Careline Counsellor at Hidden Pockets Collective, is the first point of contact for the clients who are in distress. Aisha said, “More than the fear of contracting the virus, the youth have the fear of finding out that they are pregnant and they are already panicking about safe abortion during this lockdown”. She explained that most people who reach out to Hidden Pockets have no access to pregnancy test kits as they are staying with their parents during the lockdown. When their otherwise regular periods are now unusually delayed, it sets forth a whole chain of doubt and fear that they are pregnant. To worsen their woes, they do not have the approachability to request their parents for a pregnancy test kit nor can they step out to get one on their own. Immense stress, anxiety and fear constantly swing these young people between gloom and doom. 

With the lockdown extended recently, their worries too have grown that if lockdown gets stretched further in the future, they will not be able to hide their pregnancy (if they are pregnant) as the telltale signs of pregnancy will start to show and family will realize what is happening. 

Even if necessary precautions have been taken for safe sex, the youngsters are looping in circles of worry about being pregnant only because their periods are unusually delayed. Given the drastic lifestyle changes that lockdown has brought about where sleep cycle, dietary habits and metabolic rates have all gone for a toss, the menstrual cycle is playing havoc with the youth’s anxiety levels. 

Aisha strongly felt that telemedicine guidelines, in its current form, are not addressing many challenges on the ground when it comes to access to safe abortion. She said, “the existing guidelines on telemedicine poses problems as it does not permit giving medical abortion pills. For doctors, they need scan results for abortion. Most scanning centres are non-functional during the lockdown and if they are functional the question of access during the lockdown remains.” 

With every passing day of the lockdown, the number of youngsters who reach out to Careline services of Hidden Pockets Collective is skyrocketing. As much as she wants to help them, Aisha feels her hands are tied because of the ground realities of lockdown. “Even if the government is not listening to the pleas of organizations like us and make the needed changes to the guidelines that can ensure safe access to abortion, then at least bring in as many senior doctors as possible who have vast experience to just have conversations through telemedicine with these youngsters. The reassurance these senior doctors can give to the patients can bring a lot of relief to them,” she emphatically added.

India is still making the uphill climb towards tech literacy, tech outreach and quality tech services. The dichotomy between India and Bharat are present for these tech matters too. While many continue to use these valid points as downers for supporting and promoting telemedicine, what is being forgotten is the need of the hour we are in. Young women are in distress and virgin birth might not be the best answer they can give their parents when the lockdown ends!

Writer : 

Dr Nishitha Aysha Ashraf is Programme Associate for SAAF Project at 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.

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