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 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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