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.

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!

Essentials: to be or not to be?

We all know how it went: first the Janta Curfew, then the 21 days national lockdown and, of course, the marathon run to any shop that was open and buy anything and everything that was available. If one shop did not have it all or did not have enough, we had the relay run to other shops! Run, run, run we did (well most of us did) as we were not sure whether all the shops will be open for the coming few weeks. While many did panic buying, others had panic attacks when they saw empty aisles, one after the other. As the government continued to reassure people that essential services will be there even during the lockdown, we nevertheless continued running. It appears that many of us did not trust the government enough and decided to carry on with our survival of the fittest action-moves at many shops and services. Essentially, most of us did not know what essential services are and essentially, most things in our eyes were essential!

In the wake of the lockdown, recently the Ministry of Home Affairs issued a consolidated guideline on the measures to be taken by Ministries/ Departments of Government of India, State/Union Territory Governments and State/ Union Territory Authorities.  The guideline has a list about the services, establishments and offices that are exempted from being non-functional during this lockdown. It does bring some clarity, however, it also leaves many things to the public to wonder whether X is essential or Y is not essential. One must also note down that this guideline underwent modifications on two different dates, within a span of 4 days since its first notification on 24 March 2020. 

At Hidden Pockets, we have been left in a quandary, as many of our clients continue to reach out to us through our Careline services amidst the lockdown and we have little options to help them out because many listed services are in fact non-functional at the ground level. It is a major setback to the sexual and reproductive health and rights (SRHR) of an individual. Even if one were to rationalize that during pandemics such rights can be suspended in light of the larger and pressing issues like making sure food and provisions reach out to the people, one cannot help wonder in bemusement at the skyrocketing sales of condoms during the same pandemic times. Looks like people, after all, take their SRHR very seriously even if establishments and service providers are playing coy to ensure SRHR matters need not be upheld during a pandemic. However, not all preventive or even curative measures are within the ambit of an individual, and hence the government need to make sure that services in health systems pertaining to SRHR too continue to be fully functional and shall not be sidelined citing the gravity of the pandemic. 

In the immediate days of the lockdown, there was a shortage of sanitary napkins as there was no clarity whether it is an essential commodity or not and the supply chains in turn thus got affected. Even though the Telangana and Karnataka governments had already listed sanitary napkins and many other basic hygiene products as essential goods, it took a few more days for the Central Government to issue a notice stating that sanitary napkins are also essential goods and it is this notice which is reflected in the recently modified guideline. One cannot help observe wryly that, after all the big hoo haa in news and social media around the movie Padman and its “deserved” win of the National Film Award for Best Film on Other Social Issues, it was, in fact, a virus that made government acknowledge that sanitary napkin is indeed essential! A big round of applause for Corona please and some reloaded break-the taboo social media challenge endorsed by celebrities with hashtag #wowessentialpads #dinknow #whatwasithinking ! 

As the ambiguities continue to remain about many other goods and services being essential or not, it is interesting to note that different countries have responded differently about what should go in the goody bag of essentials. States within countries too diverge about what are essential goods and services. It seems guns and viruses can get along well in many states of the United States of America. According to a memo from the U.S. Department of Homeland, the security employees of gun stores and gun manufacturers are to be seen as “essential” workers. Although the memo is advisory in nature and not a federal directive or standard, the message is loud and clear that the gun industry can be considered essential in the United States and shall not bite the bullet even during a pandemic. Shoot down the virus perhaps with all the guns? Anything is possible in the Trump land after all!

The liquor store is another “of course we need it! / what? Absolutely not in these health emergency time!” issue that is debated in many circles. Even as most countries have imposed a strict liquor ban, some states within countries have permitted the sale of alcohol. The state of Ontario in Canada has liquor stores as an essential service and explains the necessity too to have it as an essential service. The Indian state of Kerala, which has the highest per capita liquor consumption in the country, had no liquor ban even amidst the pandemic until recently. And now it has emerged that the suicide rate is increasing in Kerala due to alcohol withdrawal symptoms. The state government is approaching the issue with an order that alcohol can be prescribed by doctors for those who have withdrawal symptoms. The medical bodies have however opposed the order stating that it is unscientific and other measures such as de-addiction centres should be considered for addressing the problem. 

Essentially, the list varies from state to state and countries to countries. We still continue to see empty aisles in grocery stores, we still continue to see tonnes of tomatoes & fish destroyed by exasperated farmers and fishing communities, we still continue to see trucks with supplies stopped at many state borders, we still continue to see people walking triumphantly from shady corners of the streets with newspaper-wrapped parcels in their hands and well, now we have started to see hoards of migrants walking hundreds of kilometres under the April sun, for days and days, without food and water, just to wrap themselves in the safety of their home towns. Makes one want to think what is essential and for whom, and what is the government doing about it all. But of course, before all that, must get out soon and do the marathon run to buy oil-wicks-diyas to light up for the Sunday night 9 PM show! Hope that won’t go out of stock soon!

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 is Care

Abortion is Care

Every day, a minimum of 10 young women in Karnataka is looking for help to have an abortion. These women have limited information on where or how to access the services that can help them. They also have limited awareness of their sexual and reproductive health. Studies have found that unsafe abortions are the third leading cause of maternal deaths in India. And this is preventable if women have information and access to safe abortions. Hidden Pockets is running a campaign called ‘Abortion is Care’ to create awareness and provide accurate information on safe abortion in 4 cities of Karnataka (Bangalore, Bellary, Shimoga and, Mysore). By the end of this campaign, we hope to build an atmosphere where every woman will be able to access friendly, affordable and safe abortion services by involving the local communities from these cities.

Here are some of the videos we created for the campaign:

English: Abortion is Care 

Kannada: Abortion is Care

Tweetathons:

Instagram / Facebook Live:

  • Instagram live with Dakshita Wickremarathne (YANSL- Youth Advocacy Network Sri Lanka) on men and their support for women’s SRHR during a crisis.
  • Instagram live with Indian Women Blog on The role of sexual and reproductive health counselor during the lockdown, How are Hidden Pockets helping the young people of our country.
  • Instagram live with SHEROES India on SRHR concerns during the lockdown.
  • Instagram live with Rangeen Khidki Foundation on access to SRHR during the lockdown.
  • Instagram live with Good Universe NGO on Sexual and Reproductive Health.
  • Facebook Live with Dr. Rathnmala Desai, FPAI (Family Planning Association of India) on Pregnancy, Abortion and other Sexual and Reproductive Health Concerns.

Here are the Podcasts we created for the campaign:

Campaign posters:

 

Live sessions with students:

Live session with students from Christ University, Bangalore

Identified reproductive healthcare hotspots in four cities of Karnataka

In the month of September/2020, Hidden Pockets Collective run a campaign #knockingoncloseddoors where we mainly focussed on Abortion during Covid-19.

Campaign Collaborations #knockingoncloseddoors

  • Tweetathon with Pratigya Rights and Global Concerns India (Local Partners) on Impact of COVID 19 on Safe Abortion services in India.
  • Tweetathon with Lend a Voice Africa, Safe2Choose, The Wise up initiative, Rural women’s right structure, BALDSA, Global Media Foundation and COHERINET on Covid-19 and impact on safe abortion services around the world.

Tweetathon Moments

Abortion Stories