Abortion in Pandemic: Reality Check at the end of 2020

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!

Serial Abortionists!

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.”

Conclusion:

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. 

Writer:

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.

Aadhar & Abortion: You Will Never Believe Your Privacy is Ending

Digital campaign with its strong emphasis on the digitization of public records has seen a companion in Aadhar. From basic amenities like getting ration, getting medical services or opening a bank account, Aadhar is being made as a mandatory requirement. There is a move to link Aadhar with the health data of an individual in their entire lifetime.  This means every time an individual attends a doctor or uses a service it gets recorded and gets shared on a platform that can be accessed and would be part of the digital archive forever.

Abortion service really does not fall within this category of happy medical services.  It is one of those services that women might have to access if they do not want to proceed with the pregnancy.

There is a strong assumption on the part of our government that individuals want their health records to be saved and archived on their behalf. There is a strong belief that all the medical services undertaken by individuals are for happy and good reasons.

Abortion in India became legal in 1971 under the Medical Termination of Pregnancy Act, 1971, making India one of the first countries to provide access to abortion services in a safe manner. Even though it is highly restrictive in nature, due to conditions that are imposed on the women accessing the services, it was still a great step.

In 2002 and recently in 2020 when amendments were introduced again in the MTP Act, it was again seen as progressive steps towards making sure that women had access to better services and to make these legislations more women inclusive.

However, these initiatives have not really changed the stigma around abortion. Both married and unmarried find it difficult to access abortion. There are can be many factors, but the social stigma attached to abortion makes it really difficult for women to deal with service providers. In spite of abortion being provided in the public health sector for free, women prefer to pay a huge amount to keep it confidential. Women are forced to take this path because the social atrocities would not let her make a choice for her own body without being judged and shamed for it.

Aadhar and the privacy debate:

With the debates around Aadhar, privacy has been brought to the mainstream news. There is a lot of anxiety around the lack of a privacy bill in India and the repercussions of it. The health sector is specifically prone to it, with sensitive data like HIV, abortion and sexual orientation becoming part of health narratives. Aadhar has been pushing for digitisation of all health records which would directly affect access for services like abortion in cities of India.

With the recent re-modelling of the Indian public health system, it has been suggested by the Ministry of Health and Family Welfare that Aadhaar numbers will be used as unique patient identifiers in a new electronic health records system.

The electronic record will include previous medical history, procedures undergone, diagnosis, drugs prescribed, and which hospitals visited, all accessible on a cloud-based e-application. The notification even acknowledges the fact that some of it is sensitive data and would be dealt with under the Information Technology Act 2002, Data Privacy Rules.

On one side the government acknowledges the fact that some of the medical information is sensitive and can have different repercussions for different communities. On another side, the Attorney General in his submissions before the Supreme Court in the Aadhaar case, May 3rd, 2017 argues and contends that the concept of bodily integrity is bogus.

For activists who have been working to make abortion laws more inclusive in India, this did seem like a very regressive statement to be made by the Attorney General. Women have been fighting for their rights to their bodies for decades now. Women have always been one of the worst victims of patriarchy and bodily integrity has been a long fight battle with the state for women to have won. The debate around abortion has been fighting for the right to privacy and keeping the state away from its bodily integrity. Does linking her abortion data with Aadhar data violate her right to privacy? If women have a right to have access to abortions, they should also have a right to confidentiality. Abortion data is extremely sensitive data for single women and married women who still find it difficult to exercise their sexual and reproductive health rights.

With Aadhar becoming mandatory for every medical service, abortion becomes an extremely sensitive and difficult service to access. For a lot of young women both married and unmarried, this is sensitive data and they are really not comfortable knowing that this is being recorded and being maintained by the government.

In a data driven world, where every data becomes a value for the business, how do we ensure that our young women accessing legal services which are stigma driven are not further harassed? How do we ensure confidentiality is still maintained when they are accessing legal services? How do we make sure that women do not end up using services of quacks due to fear of digitisation of her medical records? These are questions that the state needs to engage in, instead of arguing that bodily integrity is bogus.

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 telemedicine to 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 WHO has 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 camaraderie 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.  

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 legal to 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 pregnancy up 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 UK have 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!

Young Women: Are Abortion Laws With Us?

When the news emerged on January 29, 2020, that the Union Cabinet approved the latest set of amendments to the Medical Termination of Pregnancy Act, 1971 (MTP Act 1970), many hailed it as a progressive stand on abortion laws for these modern times, as the medical technologies have been far advancing and gender equity been fast approaching. As much progressive as the Medical Termination of Pregnancy (Amendment) Bill, 2020 (MTP Bill, 2020) seem to be, it does come across as being out of touch with some ground realities.

In our work at Hidden Pockets we have been documenting many barriers that young women face when they need safe abortion.

Privacy still eludes young women: 

As much promising it is to see that the MTP Bill 2020 has highlighted the need for privacy by stating “name and other particulars of a woman whose pregnancy has been terminated shall not be revealed except to a person authorised in any law for the time being in force”, we really need to reflect whether this clause needs more specific rules and regulations on documenting the patient’s details in medical records, having this data stored and the possibilities of third parties using this data. These steps are important not just from the point of view of creating a non-judgemental service provider, but also to ensure that the law safeguards the privacy of women. Also, it is imperative that we have abortion service providers who do not bring in their baggage of judgements and personal belief system that will deny the young women their right to have an abortion. With no respect for privacy, no support system and a highly judgemental society around, many young women opt to not go to a safe abortion service provider and instead end up getting unsafe abortions that may expose them to grave infections and internal injuries.

Medical matters and doctor matters: 

No matter whether it is the MTP Act 1971 or the MTP Amendment Bill 2020, the doctors continue to be the ultimate yes/ no person who will decide whether the woman can have her abortion. An adult woman (18 years and above) who is capable of making autonomous decisions is barred from doing so here, as the case rests in the doctor’s hands. If the termination poses a risk to the woman’s life, by all means, doctors are needed in the picture to give her/his opinion. However, for pregnancy within the safe gestational limit wherein, a doctor’s decision is not warranted, the woman should have the autonomy to decide about abortion. The Centre for Reproductive Rights states that 590 million (that is 36%) women of reproductive age live in countries that follow abortion on request. 67 countries are having such legislation and the most common gestational limit in these countries is 12 weeks. Perhaps the progressive MTP Bill 2020 can take a step further and include a clause that gives autonomy to women who want to terminate a pregnancy of less than 12 weeks gestation.

Also, giving authority to doctors to ‘sanction’ abortion can take nasty turns as we have seen with our clients a Hidden Pockets. We have documented doctors extorting eye-watering charges from unmarried women for medical termination of pregnancy and some doctors have even threatened to call the parents of young adults who wanted an abortion. Perhaps we need to double-check on the authority which the law has bestowed on the doctors and that it can be misused for harassment and profits, especially when the women are in a vulnerable state.

Legal and illegal conundrum:

Even though the MTP Act 1971, clearly holds a bias against unmarried women, it was always still possible for unmarried women to get a safe abortion under the legal ambit that the continuation of the pregnancy will cause grave injury to her physical and mental health. However, the myth that abortion is illegal for unmarried women continues to persist, in the medical circles as well as in the larger society and this translates into outright refusal by many medical professionals to turn away unmarried women. Also, many unmarried women are not aware of their rights to have a safe abortion and are thus easily misled by some medical professionals who choose to give them false information. With the limited understanding of India’s existing Abortion Laws, there is a tremendous need to clarify and publicize these rights in accessible forms. It is in such a milieu that the MTP Amendment Bill 2020 has chosen to not amend the existing clause on married women nor has it chosen to clarify that it is not illegal for unmarried women to terminate their pregnancy.

Tail note: this article is based on the press release posted by PIB Delhi on 29 Jan 2020. The Medical Termination of Pregnancy (Amendment) Bill 2020 (MTP Bill 2020) is still not available in the public domain.

How much should government interfere regarding length of your pregnancy?

A spate of state abortion laws around length of pregnancy in the USA threaten the right to abortion held sacred since the landmark ruing in Roe v. Wade in 1973. Unsurprisingly, these moves come from some of the most conservative states of the country.

6-7 weeks of Pregnancy

In 2019, Georgia, Kentucky, Mississippi, and Ohio sign separate ‘Heartbeat Bills’ that prohibit abortions after the heartbeat of a fetus detects. That is at around 6-7 weeks of pregnancy. This is also around the time when most women are able to positively ascertain a pregnancy. Leaving them with little or no time to seek a termination

Meanwhile, Alabama signed into law a near absolute abortion prohibition law. Which outlaws abortions at all stages without exceptions even in cases of rape or incest. The only exception is in cases of a lethal fetal anomaly. A case of medical emergency, or where the mother suffers from a serious mental illness. Most disturbingly, these laws are often accompanied by long periods of imprisonment for both the women opting to undergo a termination, as well as the doctors performing the abortion.

24 weeks of Pregnancy

At the other end of the spectrum, New York passed a law permitting for abortions after the 24th week of pregnancy. So long as the fetus is not yet viable or the termination is necessary to protect the life of the mother.

Different weeks in Different states.

The vast differences in the level of protection and restrictions in the issue of abortion. Owes to the fact that abortion rights have always been a point of contention for The US and is often a key debate point during elections. Until 1973, abortion was a purely state regulated area. With different states having different laws on this matter, and with several states criminalizing abortion unless done to save the life of the mother.

Landmark judgment : Roe v. Wade.

The landmark moment came in 1973 in the ruling in Roe v. Wade where the Supreme Court for the first time held that women all over the country have a right to abortion. By reading this right into the right to privacy, thereby preventing states from imposing a restriction in this regard.

The Court however, did not rule in favour of absolute liberty to women to terminate her pregnancy at any time. The Court ruled that pre-natal life still constituted a valid state interest.

Planned Parenthood v. Casey

A later US Supreme Court decision in Planned Parenthood v. Casey established that this state interest in the fetus begins at the time of fetal viability. That is, at a time when the fetus can survive outside the mother’s body. The ruling while upholding the right to abortion as an integral part of exercising personal liberty. Nevertheless, permitted states to impose abortion regulations as long as they did not unduly burden women.

Since the decisions of the Supreme Court in Roe and Planned Parenthood, states have found other ways of restricting abortion and through imposition of regulations that indirectly champion the conservative cause.

Restrictions

Restrictions include mandatory ultrasounds prior to termination, compulsory waiting periods, and TRAP laws. Targeted Regulation of Abortion Providers or TRAP laws seek to impose high restrictions on centers and physicians providing abortion services that make it impossible or very challenging to establish and run an abortion centre. These laws include requirement of admitting privileges in a nearby hospital, requirement of complex and expensive facilities, etc. These laws have lead to the shutdown of several abortion centres. And resulted in some residents being more than 300 miles from the nearest abortion provider. Most of the regulatory laws are made under the garb of protecting women. But in fact, endanger the health of women as many are forced to seek discreet ways to end their pregnancy. Or forced to terminate without medical supervision. 

Challenging Roe v. Wade

The recent restrictions imposed in Alabama, Georgia, Mississippi, and Ohio. Those states however go beyond the regulatory restrictions and wage a war directly on the rights established in Roe and go against the tenets of the landmark ruling. It’s purported that this is in fact the intention of these laws. Which will ultimately force a revisiting of Roe v Wade before the Supreme Court. This move is no doubt motivated by the favorable conservative climate of the Supreme Court particularly after the two recent appointments madeby President Trump to the court.

Women’s rights in Danger?

While none of the recent abortion laws have come into effect yet, the lashout against these laws have already begun from women’s rights and civil rights groups challenging the outrageous attempt to control women’s bodies, the deprivation of privacy in their most intimate spheres of life, and assault on their bodily autonomies.

The abortion bills in Iowa, Mississippi and Kentucky have blocked by judges for now while rights groups have geared for a judicial challenge of these restrictive laws. Keeping in mind the Republican strength within the White House accompanied by the conservative majority in the Supreme Court, it is clear the health and lives of women are at grave and imminent risk.

Author: Shruthi Ramakrishnan

Shruthi Ramakrishnan is an independent legal consultant working in the field of human rights. She is available at shruthiramakrishnan0@gmail.com

Can a minor girl get an abortion in India?

A lot of young children have been asking whether they can get access to sexual and reproductive health services.

There were several schemes in the country which provides young adolescents with scope of getting information and services In the adolescent friendly healthy clinics in their city.

Can a minor get abortion?

Things that often get confusing is that even though young people can get abortion, it would be seen a criminal case and often young people get scared of this.

Things that minors should keep in mind :

A minor girl is someone who is below the age of 18 years old.

Under the Medical Termination of Pregnancy (MTP) Act 1971, a minor girl needs written permission from her guardian to get an abortion

The MTP Act defines guardian as a person “having the care” of the minor person. Thus an adult, someone over 18 years of age who accompanies a minor girl to a clinic would be De facto guardian and could consent to an abortion on the girl’s behalf.

Things that providers should keep in mind: 

If the girl’s age and/or marital status are uncertain, the providers can proceed with the termination of pregnancy in line with the provisions of the MTP Act after maintaining complete and detailed records of the case.

It is advised to report the pregnancy as per the legal requirement under  Protection of Children from Sexual Offences (POCSO) Act 2012 and allow the authorities to decide what actions to take.

What does Indian law say about abortion? In conversation with Anubha Rastogi

CREA, a feminist human rights organisation, organised a workshop on law and abortion on June 23 & 24, 2017 facilitated by lawyer Anubha Rastogi. Specialising in human rights law, Rastogi has extensive experience of working with women’s rights issues including illegal trafficking, abortion, sexual harassment,   among others. In conversation with Hidden Pockets, Rastogi spoke about right to our body as a fundamental right, laws around abortion, abortion as a right, among others.

Right to our body

How does the constitution define our right to our body?

The (Indian) constitution in the chapter on fundamental rights guarantees that each person has a right to life. Right to life has been interpreted to mean a lot of things including your personal liberty, your bodily integrity and your right to health. So that’s where the constitution actually brings in the fact that each person in this country has a right over his or her own body.

What are the rights that women enjoy with respect to their sexual and reproductive health?

If I look at laws, we have the Medical Termination of Pregnancy (MTP) Act from 1971 where the language is not in a rights based format but it has been providing access to women who want to terminate pregnancies and then there’s the Maternity Benefit Act which now has recently been amended to expand its own scope. Then there are legislations that have come in as a result of offences against women like the Domestic Violence Act, the Protection of Children from Sexual Offenses etc. But having said that, the Constitution treats each person as an equal and with that also provides the space for the state to make any special provisions for women and children and within that there are a lot of progressive policies and legislations which have been made for women.

Abortion as a right

How does the Medical Termination of Pregnancy (MTP) Act view getting an abortion? Does the act confer the right to abort on women?

The MTP Act is worded in a way in which the medical termination of pregnancy is based on medical opinion. So there is no on demand abortion in this country. And the MTP Act also lays down the conditions under which the pregnancy can be terminated. A registered medical practitioner can go ahead and terminate the pregnancy only based on medical opinion in the existence of any of these conditions. So in a sense even though since 1971 there is official legal access to termination of pregnancies, it’s not a right. It’s only one judgment of the Bombay High Court that has viewed the existing law from the lens of the woman and has termed it as a right. But the legislature is still not looking at it as a right.

What are the rights conferred by the Act on an unmarried women? is it illegal for an unmarried woman to get an abortion in India?

See the law is saying that where a woman is pregnant and it is an unwanted pregnancy and in the opinion of the doctor, the unwanted pregnancy will impact or have a grave injury on the woman’s physical body or her mental makeup then definitely the pregnancy can be terminated. Where the reason is contraception failure that is available only for married women. Where the pregnancy is as a result of rape and the woman is a major, there the woman can definitely seek termination of pregnancy and that can be provided to her irrespective of her marital status.

What are the amendments that have been proposed under the MTP act?

The amendments that have been proposed in the MTP Act are definitely to look at on demand abortion at least up to 12 weeks. There has been a proposal of increasing the 20-week limit to 24 weeks or 26 weeks. I think that stand keeps changing. One of the things that they are asking for is to increase the provider base because it’s with the appropriate training. So it’s not necessary that it’s only a MBBS doctor who can provide the MTP service. If legally, the law accepts it, with appropriate training even other service providers can provide this service safely. There has been a move to increase some other reasons for which an MTP can be provided. Those are some of the key amendments that are being sought.

Will abortion become a right if the on-demand abortion up to 12 weeks gets passed as an amendment?

Yes

Terms of the abortion as per MTP Act

What are the circumstances under which abortion can be done as you say under the MTP Act?

The MTP Act determines the length of the pregnancy as one of the factors. With respect to the length of the pregnancy (within which pregnancy can be terminated), the Act mentions 12 weeks and then there’s 20 weeks. If the pregnancy is as a result of sexual abuse or rape, she can get an abortion. It also allows for abortion where it’s a married woman and there is a contraception failure and therefore the pregnancy is unwanted. It also gives two instances as illustrations of what can be considered as a circumstance which will have a grave injury on the woman’s either physical condition or her mental setup. That is definitely one of the main reasons why many MTPs are done and can be done. The pregnancy may be terminated where there is any abnormality in the fetus, a history of disability in the family and a substantial risk that the fetus when comes to term and the child when born would suffer from some serious disability or would be handicapped, a term which the law uses. Apart from that it also provides for a registered medical practitioner to terminate a pregnancy at any point in time of the pregnancy irrespective of what the law otherwise says where it is to save the life of the woman.

Which is a place where someone can get an abortion? Is anything defined in the MTP act?

The MTP Act says that any government hospital is already a place that is approved where an MTP can be provided. For private setups, the MTP Act provides for a committee to be set up at every district level that will take applications and do an inspection of the place that has applied to become an MTP centre. Once it’s approved, the committee will give them a certificate and will continue inspecting it and keep an eye ensuring that quality is maintained. So these are the two kinds of places where officially legally an MPT can be done.

PCPNDT Act and MTP Act: The conflict

What has been the effect of PCPNDT Act on MTP Act? Does PCPNDT make it illegal to get an abortion?

PCPNDT Act and the MTP Act, both acts have their scopes very clearly defined and they do not in any way merge or overlap with each other or hit each other. The PCPNDT Act only talks specifically about the regulation of clinics or technology that can provide sex determination (and selection) services. So the PCPNDT act makes it illegal for selecting the sex of the foetus and makes determining the sex and communicating the sex of the foetus an offense. And that’s where it stops. It does not say anything about what happens once a person knows the sex of the foetus. The offender under the PCPNDT Act in most cases is the expert, the radiologist or the technical expert who is able to understand and use the technology or misuse it. The MTP Act in its scope very clearly provides for situations when a pregnancy can be terminated and that’s all it says. If a woman is falling within any of those categories and on medical opinion, a registered medical practitioner is terminating the pregnancy there is no offense that has occurred under the MTP Act or under the PCPNDT Act at least by the provider who has provided the service. There may be an offence committed by someone under the PCPNDT Act. The person may have communicated the sex of the foetus but nothing else in this whole chain of events. The scope of the PCPNDT and the MTP Act has actually affected women in accessing MTP services in a large way. From what I hear, many doctors are now afraid or are reluctant to provide MTP services because of which there is a possibility of some kind of restriction or inspection that they will have to face.

How has the sex ratio in India been affected by the PCPNDT and MTP Act considering that a certain association is constantly made in this conversation with respect to these Acts?

The gap between the number of girls born per 1000 male children born was increasing. Because of the declining child sex ratio, it was understood that this is happening simply because there is gender based sex selection that is taking place.

This gave the PCPNDT Act lot more teeth. When the Act was amended in 2003, several new technological developments were brought into the fold of the law. But very clearly the PCPNDT talked about the fact that the offense is the determination of the sex of the foetus and its communication. Without that information even if a woman or a family is seeking a MTP, it doesn’t really make a difference. The problem has been that the focus has completely moved from the service provider or the expert to the woman, her pregnancy and what is she doing with the pregnancy while that, in the domain of law is not really an offense. What has now happened is that states are being asked to provide child sex ratio numbers on a monthly basis. Districts have been asked to provide these on a monthly basis. I’m not a statistician so I’m not very clear but I’m told that it takes about at least 3-4 years to determine child sex ratio or sex ratio of the adult population. It’s obvious that those numbers are not accurate where we are asking districts to provide these numbers on a monthly basis. But those numbers are being quoted and this is having its impact on access to MTP centres and people are refusing to provide MTPs as a service. Obviously, then it has its impact. There is a lot of push to implement the PCPNDT Act in different ways because of these numbers.

What was the PIL related abortion that you had worked on, in the state of Chattisgarh?

This was a writ petition filed as a Public Interest Litigation before the Bilaspur High Court in the state of Chhattisgarh. Before filing the petition, there were a lot of Right to Information applications that I had filed to know whether the District Level Committees have been actually set up in every district in the state of Chhattisgarh and what is the number, how many times in the past year did they meet, how many centres and how many applications have they decided upon. In Chhattisgarh, out of the almost 27 districts, some of them did not respond (to the RTI request) and 10 of them responded back saying that they had never set up a District Level Committee.

National Alliance for Maternal Health and Human Rights became the petitioners. They also have members from the state of Chhattisgarh. This petition was basically filed to ask for district level committees to be set up and to also ask for government hospitals to ensure that MTP services are provided and that they are as per law. We used the RTI data, the data that was available in the public domain about the condition of access to Medical Termination of Pregnancy services in Chhattisgarh and with individual stories of other woman and some clinics in Chhattisgarh (to file the PIL).

The case was decided in January 2017. When the petition was filed in 2014, I think there were only 30 registered centers that were available and at the end of the petition, there were 150 centers that were available.

Data that the state gave showed that they had actually done a fabulous job. Even though this was on paper, we still wanted an opportunity to be able to counter what the state is saying on paper but we were unfortunately not given that opportunity. But even then an increase from 30 to 150 is quite high even if it is only above 50 percent accurate. That is still some access that has been created because of this petition. It also enumerated the number of professionals who have been trained under the MTP Act to be able to provide MTP services. That had also drastically increased. We had also asked for other things in the petition where we said that not only should a government hospital or a private clinic be prepared to provide for MTP but it should also be prepared to deal with any eventuality. There should be access to blood banks, clean water, electricity etc. but all of those things were not really dealt with by the court and the matter was disposed off.

Abortion in Bengaluru Urban: Part 1

*This article is a part of a series exploring the abortion services in 4 districts of Karnataka.

COVID-19 pandemic has tectonically shifted many things in everyone’s lives. When the nationwide lockdown was all about highly restricted movement and access, only essentials being available, and night curfews; then the nationwide unlock stages were all about “are we there yet questions” on getting back the pre lockdown normal life. 

When Hidden Pockets Collective started its tele-audits of service providers for abortion, we were in the cusp of the country moving from the lockdown to unlock. The month of June saw us glued to our phone, making calls after calls to every listed government-run Maternity Homes (MH), Referral Hospitals (RH), General Hospitals (GH) and Tertiary Hospitals (TH) in Bengaluru Urban district. This was just the start to an extensive project where we were to audit three more districts viz Mysore, Shimoga and Ballari in the state of Karnataka. 

To know more about this  SAAF (Safe Abortion Action Fund) project “Abortion is Care”, do read:

With unlock in full swing at various stages, we were very hopeful that Bengaluru Urban will soon be back on its buzzing feet. On that note, when we started making calls to the 30 plus listed abortion service providers that fall under the categories of MH, GH, RH, and TH, we were rushing against time to put together all the collected information for young women. Abortion is a time-sensitive matter and with lockdown cutting off SRHR access to numerous women, we were sure that we will be the SOS call for many women. But we were in for a rude shock from Bengaluru Urban!

Let’s not answer. Let them die or whatever?

Of the 30 plus listed service providers, many did not answer our calls! Mind you, these are listed landline numbers that the public is expected to use when they need information, clarification on healthcare services from the hospital. The inquiry desk of the hospitals is literally the ones who should be at the beck and call through this number. However, during the month of June, many of these hospitals chose to do a “Marie Antoniette” at the public by absolutely refusing to pick any calls. We were quick to dismiss these “refusals” by justifications such as probably busy hour, probably busy day, probably staff break hour. And day after day, hours after hours, we kept trying, again and again, to have someone from the helpdesk talk to us. Nothing worked! We just could not fathom how people in distress, say due to a miscarriage or labour pains can breakthrough this “refusal” to get help during the unlock, when the public had no clue how things are getting back to normal during the unlock. Forget about getting information on abortion, when in fact there is nobody to pick the call even to answer the most important question of that time: “I think I have Corona. What do I do? Where do I go?”

Yes, speak to us!

It was always a “hallelujah” moment when the calls were answered. When the audits for Bengaluru Urban were done, the total number of hospitals that answered our calls could be counted in fingers. However, it was not all rosy either when our calls were attended.

Volleyball the call:

One Referral Hospital had the staff unwilling to give us any answers to our inquiries on termination of pregnancy. Our call was volleyed from one staff to the other. They all came across as extremely uncomfortable to disclose any information on abortion over the call and kept dismissing us by stating that we need to come in person to the hospital, meet the doctor and get a check-up done. In spite of our repeated stand that we were currently not in a position to physically travel to the hospital due to the pandemic and that we just need some basic information regarding the cost such that we come prepared for the termination later when we make the trip to the hospital,  the staff reiterated to their tone-deaf words “come to the hospital, get the OPD ticket, meet the doctor.”

Doctors wanted:

A few hospital help desk staff were able to give us preliminary information. However, for details on gestation limits and type of abortion recommended, they were unable to help us as they openly admitted that they don’t know anything about such matters. They suggested we speak to the doctor and connected us to the department landline. Often the doctor on duty was unavailable to attend the call, as they were either in O.T or doing the ward rounds. There were also doctors who were unavailable as they were on leave or were away attending a district-level meeting with health department officials to manage the district’s response to the COVID-19 pandemic.

Only Corona please:

A leading government hospital answered our calls with promptness and professionalism. We were almost on the brink of relief thinking that this hospital will finally be the go-to-place for safe and legal abortion for all, irrespective of the marital status. All hopes were dashed when they told us that the entire hospital has been converted into a COVID-19 hospital and they can take in only COVID-19 cases! Our question on where else can a patient go to get OBG consultation, now that hospital X is COVID-19 one, were met with apologies from their end: they did not know where the patients were to go!

Conditional abortion only:

Of the two hospitals that gave us a positive response for medical termination of pregnancy, one came across as too eager to get rid of us using scare tactics. The doctor of this hospital who spoke to us said that we need to get permission from the Medical Superintendent to get an abortion! She said this is needed because the abortion is for unmarried women. 

The second hospital whose doctor was very understanding of the predicament of any women-married or otherwise- to get an abortion, did offer abortion services according to the provisions of the MTP Act, 1971. However, the doctor did put forward the suggestion that it is always best that there is a patient bystander who can help and support the patient during the abortion. She said that they have had cases in the past when the patient was abandoned by the bystander when any complication such as excessive bleeding occurred. Hence, she was of the opinion that a person who has the legal obligation to the patient be the patient bystander. 

Pre pandemic and post pandemic:

Our field trips were severely curtailed by the pandemic. Had it not been for the pandemic, we would have been stalking the corridors of all these hospitals, talking to the patients and doctors there, trying to assess and evaluate on the ground, such that we have concrete data on safe spaces for women to seek a legal abortion. With the country gradually settling into the “new normal” of post lockdown months, we are looking forward to being on the ground.

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.

Abortion in Mysore: Part 1

Sex, pregnancy, babies: taboo subjects? Absolutely not! Not if you are married. The Indian cultures and societies validate, sanction and many even celebrate these when you are married. But, what if you are not married? All it takes is the unmarried status to make these matters into – “mooh kala kardi”- shame, dishonour and guilt. 

India has its largest ever adolescent and youth population. According to UNFPA projections, India will continue to have one of the youngest populations in the world until 2030. The Guardian reports 600 million people are under 25 years of age. That is more than half of India’s population. Do you think they all wait to get married to have sex, get pregnant and have babies? Sexuality is being explored by the youth. However, cultural and societal taboos continue to exist in many parts of India. And no surprises, it is always the unmarried women who bear the brunt of it all, especially if she is pregnant. 

Ironically, India has one of the most liberal laws in the world when it comes to termination of pregnancy. However, it is no relief when you realize the barriers that women have to overcome in accessing safe and legal abortion in India. According to reports, 56% of abortion performed in India is estimated to be unsafe. That is more than half of the estimated 6.4 million abortions that happen in India every year. If that does not worry you, then perhaps this can: unsafe abortion is the third leading cause of maternal deaths in India.

The Hidden Pockets Collective way

The collective is using technology to increase awareness of sexual and reproductive rights amongst the youth. Using multiple platforms in social media, it has been striving to increase both awareness and access for youth to address their concerns on sexual and reproductive health & well being. Collective is the first organization in India to have a real time Whatsapp Careline service where the youth can reach out for help.

SAAF (Safe Abortion Action Fund) project “Abortion is Care”

Focusing exclusively on 4 districts in Karnataka (Bengaluru, Mysore, Shimoga and Ballari) Hidden Pockets Collective has been working on SAAF (Safe Abortion Action Fund) project “Abortion is Care”.

Safe and legal abortion should no longer be a matter which is out of reach for the youth in these districts and the project is making it happen. 

Hidden Pockets Collective launched an extensive mapping and auditing of hospitals, clinics and doctors, in these four districts, who are authorized to give abortion according to the mandates of the MTP Act, 1971. 

The challenges were numerous to carry out an in-person audit during the weeks of lockdown when the country had come to a stand still. Hidden Pockets adapted to the lockdown by launching the preliminary call audits, at the same time anticipating ease in access to these 4 districts to do the in-person audits, during the lag phase of the pandemic, The call audits findings were a mixed bag. Many doctors from all the four districts, outrightly said no to take up cases of unmarried women. Some doctors, however, gave us the hope that not all roads are closed. 

Read: Abortion in the Steel City Ballari: Part 1

Read: Abortion in Shimoga: Part 1

Mysore: not a bleak picture after all!

Mysore, apart from its fame for being a sought after tourist destination in India, is an emerging hub for techies. Many youngsters from all over the country throng the place for launching their career in the Information & Technology industry. You could even say Mysore is a youthful district! When we started our call audits, we were wondering what will happen to the youth during the pandemic when they want to avail SRHR services, especially abortion services. 

Doctor A, who is a consultant OBG doctor at a few private hospitals in Mysore, revealed that in one of the private hospitals where she works, they get numerous cases of young unmarried women who want termination of pregnancy. This, of course, was in the pre-pandemic times. The hospital which provides both medical and surgical termination of pregnancy has had cases where young unmarried women have approached them and were hesitant to provide ID proofs. Doctor A revealed that some of the doctors, including her, have helped even such cases. However, she insisted to us that it is always better that women provide ID proofs.  

Doctor A came across as a person who is not very judgemental. When speaking about abortion for unmarried women, she was direct and had no qualms about giving them an abortion. This came as a surprise to us because many doctors we spoke to in Mysore were very uncomfortable about helping unmarried women.

We were impressed when Doctor A said that, for women to get the termination of pregnancy, there is no need for parents’ or partner’s signature. Doctor A added that as long as the woman is an adult, she can give her signatures wherever needed for the abortion. 

But of course, Doctor A did not open up to us so quickly to reveal all these. In the earlier part of the phone call with her, she spoke to us in a matter of fact manner as a doctor would speak to a patient. But when we went on to ask many a question, she got defensive and wanted to know who we are, what exactly we are looking for, why we are asking her so many questions. And we had to reveal to her about Hidden Pockets Collective. It was only after a lengthy disclosure which she patiently listened to, did she open up to us and gave us the needed information. 

Mysore did the unthinkable!

When we made our calls to a top private hospital in Mysore, which is part of the hospital chain spread all over India, we were very sure that there won’t be any hassle for unmarried women to get termination of pregnancy at this hospital. After all, this hospital brand stands for corporate and profit culture when it comes to healthcare delivery. But our audit calls shocked the lights out of us!

Doctor B, who works at this hospital told us that for procedures were signatures are needed, it was not enough for an adult woman to sign. The hospital wants the signatures of either the husband or the parent or any first degree relative to give consent as well. Doctor B, went onto stress that for unmarried women, her partner can give the signature and if he is not physically present with her, then the consent can be sent through fax to the hospital! We were flummoxed! “Fax? They want fax from the partner stating consent? What if the partner is nonexistent? What if the fax can be faked?” we were left wondering! We did not ask her for clarification because it was very loud and clear that the hospital was not at all helpful to unmarried women. 

Field work 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 Mysore. Our preliminary search, so far, has given us the narratives from doctors. We are eager to meet the communities and youth of Mysore 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 Mysore 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.