Financial inclusion for the disabled in India: demonetisation and beyond #makeyourcityinclusive

In the life of a disabled bank employee on the day of the demonetisation

Prem Kumar*, 55 years old, disabled bank clerk with polio, Central Office of a nationalised bank in Chennai

  • November 9, 2016, 9.30AM: Prem Kumar has Rs. 70 in his wallet enough to take him to his office by auto-rickshaw. He always withdraws only Rs. 400, never Rs. 500 or 1000 because auto drivers don’t give change.
  • 10.00AM: Prem Kumar tries to withdraw cash from the ATM in his office. The ATM is out of service.
  • 10.30AM: Prem Kumar asks his office messenger to get him cash from the bank branch next door.
  • 11.00AM: After accepting the cheque, the messenger is asked to come later to collect the cash. Cashier in the branch serves the customers first, setting aside Kumar, a colleague’s cheque.
  • 1.00PM: Prem Kumar goes back to the ATM on the ground floor during lunch break to withdraw cash. The queue is long. Unable to stand for too long, he goes back to his office to come back later.
  • 3.30PM: Kumar goes down again from his desk on the fourth floor to the ATM. The ATM door has a notice that reads, NO CASH.
  • 5:00PM: Prem Kumar’s regular auto driver comes to pick him up from the office. Kumar boards the auto without cash. Being a regular customer, the auto driver gives him a day’s credit.
  • 6:00PM: Cashier issues the cash to the messenger.
  • November 10, 2016, 10:00 AM: Prem Kumar arrives at the office in an auto, collects cash from the messenger and pays the auto driver.

Being a disabled clerk in a nationalised bank, Prem Kumar considers himself to be among the most privileged. Most other disabled citizens of India didn’t think on the days following the announcement of demonetisation. Narendra Modi, the Prime Minister of India announced the demonetisation on November 8, 2016 while the announcement for separate queues for senior citizens and the disabled was made only on November 14, 2016.

“My friend in rural West Bengal, had to go to a bank for three consecutive days along with an escort to withdraw cash. He is visually impaired,” says Anirban Mukherjee, Executive Member of the National Platform for the Rights of the Disabled (NPRD), Kolkata. “This has hit us pretty hard. Even in Kolkata, our friends are having problems. Getting the notes exchanged is also a very difficult thing. We have to fill in forms which cannot be managed without assistance. Standing in a long queue with someone escorting you, it actually becomes pretty precarious,” he adds.

Reserve Bank of India regulations to make banking accessible

In 2007, India ratified the UN Disability Convention. This Convention provides that states that ratify it should enact laws and measures to improve the rights of the disabled and also abolish laws, regulations and practices that discriminate against the disabled. Following this, the Reserve Bank of India (RBI) passed its circular in November 2007 regarding people with autism, mental retardation and other conditions while in June 2008, it passed the circular addressing the problems faced by the visually impaired customers. Subsequently, there have been multiple rounds of changes in the standards set by the RBI to improve banking access to persons with disability. This includes opening and operating accounts, ATM access for the visually impaired and physically disabled, accessible websites, ramps in ATMs and banks, among others.

Talking ATMs for the visually impaired have also been launched by several banks across India. According to TalkingATMIndia.org, as of March 31, 2016, there are 9753 talking ATMs in the country. This includes Union Bank of India (1650+ talking ATMs), Citibank (106), Bank of Baroda (167), State Bank of India and associated banks (2882), HSBC (65), Deutsch Bank (32), Corporation Bank (2), Standard Chartered Bank of India (231) and Kashi Gomti Samyut Gramin Bank.

The accessibility gap continues

Even with regulations and policies, the problems seem to continue. Being visually impaired, Anirban Mukherjee notes that it is hard to find banks that are friendly to people with disability. “This is a general statement, not just with respect to the demonetisation. If there are banks which are disabled friendly then it is purely an exception and an accident. Locating an ATM is also very difficult,” he adds.

While TalkingATMIndia.org is one platform that provides access to this information, access to information about these accessible ATMs still seems to be a big concern. This information should be available on the bank’s website.However, a website audit of nationalised banks’ websites conducted by Maxability shows that all the top ten nationalised banks have accessibility violations on their website.

Gets worse with disabled women, and disabled in the rural areas

Disabled women and others with disability in the rural areas face higher ordeals with respect to demonetisation and access to any financial services even otherwise. “Women with disability have even lesser access to services especially financial services. They find it difficult to even come out without a family member’s support. They will not be allowed to even open a bank account because the family wouldn’t think that she is productive enough or see that she would need a bank account for her personal expenses. They have a derogatory attitude towards women with disability. That is the attitudinal problem,” notes Shampa Sengupta from Sruti Disability Rights Centre.

There is also the infrastructural problem. Having worked in the field of disability rights for over twenty five years, Sengupta notes that a very large percentage of disabled people do not have bank account or even a disability certificate. ID proof like Aadhar card is often denied to them. Even getting a disability certificate is difficult for most of them considering that it requires a valid address and ID proof. “ID and address proof is not available with a large number of people with whom we work with in the community. This is not an issue for disabled people from the affluent class. But majority of them come from poor families,” adds Sengupta.

Proof of address becomes a problem for them because they live in pukka houses. Therefore, opening a bank account meeting the KYC (Know Your Customer) norms which requires a valid address and ID proof is not possible. The situation has gotten worse with demonetisation considering that most of them work in the informal sectors and get paid in cash. Most of them have a monthly family income of around Rs. 5000. Those paid with five hundred rupee notes are finding it hard to get them exchanged. Though public spaces like petrol bunks are supposed to accept the old notes, many of them take a commission in the money exchanged if exchanged without filling petrol. This makes the situation of the disabled from with lower income far worse than the rest.

The gap is real!

Reserve bank of India may have passed circulars to make financial services inclusive, may be even mandated a separate queue for the disabled. And the current demonetisation happening in the country might have brought much of the black money to light. That said, its impact on those not included in the system is far higher. The question is will the government pay the price for the cost on the lives of these affected citizens or will people continue to be the ones to bear the weight?

*Name changed for reasons of anonymity

Do people living with HIV have a right to protect their health data?

“Consequently, as new cases brought new issues and problems before the Court, the content of the right to privacy has found elaboration in these diverse contexts. These would include telephone tapping (PUCL), prior restraints on publication of material on a death row convict (Rajagopal), inspection and search of confidential documents involving the banker – customer relationship (Canara Bank), disclosure of HIV status (Mr X v Hospital Z), food preferences and animal slaughter (HinsaVirodhakSangh), medical termination of pregnancy (SuchitaSrivastava), scientific tests in criminal investigation (Selvi), disclosure of bank accounts held overseas (Ram Jethmalani) and the right of transgenders (NALSA). Early cases dealt with police regulations authorising intrusions on liberty, such as surveillance. As Indian society has evolved, the assertion of the right to privacy has been considered by this Court in varying contexts replicating the choices and autonomy of the individual citizen.” – Supreme Court, Justice K.S. Puttuswamy and ANR. Vs. Union of India (2017)

The recent historic Supreme Court judgement that declared right to privacy as a fundamental right (guaranteed under Article 21 of the Indian Constitution) with reasonable restrictions,has looked at the intersection of privacy and medical jurisprudence in cases previously dealt with by the Supreme Court of India. Interestingly, this intersection has also included HIV and the right to privacy.

Existing challenges faced by HIV High-risk groups:

This judgement becomes especially more relevant for the members of high-risk groups living with HIV. National AIDS Control Organisation (NACO) classifies Female Sex Workers (FSW), Men who have sex with men (MSM), Transgenders (TG), Injecting Drug Users (IDU) and Truckers & Migrants as the high-risk groups most susceptible to HIV. It is worth noting that members from these groups are required to fill-out group specific application forms prescribed by NACO while testing for HIV. Though the National AIDS Control Programme is in Phase IV, these high-risks groups have been facing various degrees of challenges.

Apart from social prejudice, transgender community faces issues with valid identification document due to their gender identity. Often the gender and name on their official identification documents is different from the name and gender that they identity. Though the NALSA judgement 2014 gave them the right to their gender identity, procuring valid identification documents continues to be a challenge for the community. It is worth noting that Section 377 of the Indian Penal Code criminalizes the act of homosexual intercourse.This could apply to both MSM and transgenders. Due to the social stigma associated with their identity, it becomes significantly difficult for members of the transgender group, MSM and sex workers to reveal their identity in HIV testing centres, notes PawanDhall, Gender and Sexuality activist, Varta Trust and ex-Country Director, SAATHII. There is also the challenge of negligence from the hospital or testing centre staff with respect to revealing their identity or HIV status.

“No matter how much we say or NACO says why is that a lot of people ever want to go for a test on their own? It is because of their confidentiality being compromised. There have been so many examples of people saying that the problem begins once the counsellor sends the person to the lab technician for the test. You will give your blood and go back home. If your test is positive on the day you come back you are almost at the mercy of the lab technician or the counsellor. If their mind is not in the right place, they will talk about it out loud and people all around will come to know,” notes Dhall.

Aadhaar integration for HIV programme and the issues:

The government intends to establish integrated health information architecture to strengthen health surveillance, establish registries for diseases of public health importance by 2020.National Health Policy 2017 suggests exploring the use of Aadhaar for identification with heavy emphasis of privatization of healthcare in the country. Hence NACO’s website mentions initiating a project to link all PLHIV (People Living with HIV) to the Aadhaar card. It is not clear though if it has been mandatory.

However, it appears that some states (Madhya Pradesh andRajasthan)have mandated this linkage even with the Supreme Court saying that it is not mandatory to link Aadhaar. Though Aadhaar integration was expected to solve the issue of duplication of enrolment at ART centres for HIV treatment, it on the other hand, seems to have aggravated the situation. Patients have been avoiding registration with Anti-Retiroviral Therapy (ART) centres for treatment in Madhya Pradesh since this integration, notes Hindustan Times. Speaking to the India Express, about a 37 year-old sex worker diagnosed with HIV in Mumbai, PoojaWalawalkar, project manager for NGO Aditi says, “She fears that her neighbours will come to know if after linking the Aadhaar card some health worker turns up at their door.” The report also states that several sex workers get treated under a different name to conceal their identity. It is worth noting that presently (NACO Annual Report 2016-17), FSW (6,03,236), MSM (2,06,007), IDU (1,21,840), TG (29,325), Migrant (29,25,882) and Trucker (9,29,675) are under the Targeted Intervention Programme of NACO that works on preventive interventions for high-risk groups. Aadhaar linkage also aims at reducing the ‘Lost to Follow-Up’ cases who have dropped out of the ART centres and discontinued their HIV treatment.

“Aadhaar will definitely help you have unique listing but how that in itself will help in making sure that the person comes back again and again to get the medicines, that I’m not quite convinced,” notes Dhall.

Apart from privacy, there is the risk of exclusion due to authentication failures and deactivation of Aadhaar without recourse for the Aadhaar holder. So there seems to be no guarantee with respect to reaching out all that the programme is intended for.

It is worth noting that when a crime related to personal data occurs, UIDAI is not under any legal obligation to inform the Aadhaar user. Under Section 47 (1) of the Aadhaar Act, only UIDAI has the exclusive power to make complaints in case of violation of privacy or data breach.

What will change with Right to Privacy judgement?

Even prior to mandating Aadhaar, people living with HIV have been facing social stigma when their HIV status has been revealed. What is the protection assured to them against harassment, once their Aadhaar biometrics and phone numbers are also entered into the system to access healthcare? While there may be legal protection by way of the HIV Act, Medical Code of Conduct, Supreme Court’s judgement declaring right to privacy as a fundamental right, will that 37 year-old sex worker understand her legal and fundamental right to privacy as a citizen? Will the knowledge of the right to privacy be sufficient to handle the social stigma?

Addressing this concern, in its right to privacy judgement, the Supreme Court states that “elements of privacy also arise in varying contexts from the other facets of freedom and dignity recognised and guaranteed by the fundamental rights contained in Part III;”

“In State Vs Kharak Singh, the Supreme Court says right to life does not mean a mere animal existence, which means a life of dignity. In the event of intentional or unintentional disclosure of my HIV status or any other status, which might strip me of my dignity in the eyes of the society , no amount of punishment to the persecutor or compensation to me can bring that dignity back to my life for the rest of my life. This is where the state, even before saying that it should punish and compensate must put into place the process such that the citizens of India are not stripped of their dignity,” says Kaushik Gupta, lawyer and social activist explaining the impact of any breach of privacy at a personal level of any individual.

However, the consequence of the right to privacy judgement with respect to the impending Aadhaar case in the Supreme Court of India is yet to be seen. The right to privacy judgement has however taken cognizance of informational privacy especially with respect to sensitive data. It says:

“Informational privacy is a facet of the right to privacy. The dangers to privacy in an age of information can originate not only from the state but from non-state actors as well. We recommend to the Union Government the need to examine and put into place a robust regime for data protection. The creation of such a regime requires a careful and sensitive balance between individual interests and legitimate concerns of the state. The legitimate aims of the state would include for instance protecting national security, preventing and investigating crime, encouraging innovation and the spread of knowledge, and preventing the dissipation of social welfare benefits. These are matters of policy to be considered by the Union government while designing a carefully structured regime for the protection of the data. Since the Union government has informed the Court that it has constituted a Committee chaired by Hon’ble Shri Justice B N Srikrishna, former Judge of this Court, for that purpose, the matter shall be dealt with appropriately by the Union government having due regard to what has been set out in this judgment.”

However, the onus now rests on the Committee chaired by Shri Justice B N Srikrishna and the Government of India to protect the interests of the citizens. The impending petition challenging the Government’s move to make Aadhaar mandatory for social welfare schemes in the Supreme Court will be a defining judgement for the rights of Indian citizens.

Cracking HIV and COVID-19 code

I am living with HIV, how might I forestall COVID-19? This is rising stress during COVID-19 dread.

Individuals living with HIV who have not achieved viral suppression through antiretroviral treatment may have a compromised immune system that leaves them vulnerable to opportunistic infections and further disease progression. At present, there is no evidence to suggest that there is an increased risk of infection, though this can rapidly change as the virus spreads.

The guidance for individuals living with HIV is the same as for everybody. On the off chance that you are feeling unwell – you have a persevering dry cough and a temperature – remain at home and call your wellbeing specialist. They will have the option to educate you regarding the following stages. During this time, make sure you avoid close contact with others.

Tips on COVID-19 for individuals living with HIV
  • Try to stock-up on your antiretroviral treatment for at least 30 days.
  • Ensure your immunisations are up to date (influenza and pneumococcal vaccines).
  • Make sure you know how to get in touch with your health care facility and that you have a plan in place if you feel unwell and need to stay at home.
  • Make sure you are eating well, exercising as best you can (at home), and looking after your mental health.
  • If staying indoors is difficult for you, keeping in touch with people remotely, such as online, by phone or by video chat, can help you with staying socially associated and intellectually sound.
  • Keep an eye on advice from WHOPublic Health Department, and your doctor.
Can antiretroviral be used to prevent infection with the virus that causes COVID-19?

After conducting two studies, one of the studies suggested that the occurrence of MERS-CoV infection was lower among health workers receiving LPV/r (lopinavir boosted with ritonavir) compared to those who did not receive any drugs; the other study found no cases of SARS-CoV infection among 19 PLHIV hospitalized in the same ward of SARS patients, of whom 11 were on antiretroviral therapy. Again, the certainty of the evidence is very low due to the small sample size, variability in drugs provided, and uncertainty regarding the intensity of exposure. Several randomized trials are planned to assess the safety and efficacy of using antiretroviral drugs – mainly LPV/r – for treating COVID-19, in combination with other drugs. Results are expected from mid-2020 onwards.

Currently, there is insufficient data to assess the effectiveness of LPV/r or other antivirals for treating COVID-19.

Again, as part of WHO’s response to the outbreak, the WHO R&D Blueprint [8] has been activated to accelerate the evaluation of diagnostics, vaccines, and therapeutics for this novel coronavirus. WHO has also designed a set of procedures to assess the performance, quality, and safety of medical technologies during emergency situations.

If countries use antiretroviral for COVID-19, are there concerns about treatment shortages for individuals living with HIV?

If LPV/r is to be used for the treatment of COVID-19, a plan should be in place to ensure there is adequate and continuous supply to cover the needs of all individuals already using LPV/r and those who will need to begin treatment. However, a relatively small proportion of individuals living with HIV are on regimens which include LPV/r, since it is used as a second-line regimen according to WHO’s HIV treatment guidelines. Any country that allows the use of HIV medicines for the treatment of COVID-19 must ensure that an adequate and sustainable supply is in place.

Stigma, Discrimination, and Human rights

People need to realize that the coronavirus can infect any human being, but it seems to have spread a more venomous infection into certain minds dealing with racism and stereotyping. It can put everyone at risk. Many people could counterfeit not to have the infection in view of being terrified of being named as “the one with the Coronavirus”.

We all have the responsibility to correct the misconceptions.

Source:

a) https://www.avert.org/coronavirus/covid19-HIV

b) https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-hiv-and-antiretrovirals

भारत में मेडिकल गर्भसमापन के लिए प्रक्रिया और लागत क्या है?

क्या हमें भारत में चिकित्सा गर्भसमापन के लिए ज्यादा पैसे का भुगतान करना होगा?

भारत में गर्भावस्था की चिकित्सय समाप्ति सिर्फ कुछ शर्तों के तहत कानूनी है जिसकी अनुमति किसी पंजीकृत मेडिकल प्रैक्टिशनर द्वारा दी गयी हो। गर्भसमापन की प्रक्रिया को समझना हमारे लिए महत्वपूर्ण है।

गर्भसमापन या जो मेडिकल टर्मिनेशन ऑफ प्रेगनेंसी (एम0टी0पी0) के रूप में भी जाना जाता है के लिये महिला को एक सहमति फॉर्म भरने की आवश्यकता होती है जिसे ‘फॉर्म‘ सी कहा जाता है। चिकित्सीय गर्भसमापन करने के लिए केवल महिला की सहमति आवश्यक है।

गर्भसमापन के लिए दवाएं एक स्त्री रोग विशेषज्ञ द्वारा लिखी जानी चाहिए।

महिला को एक दवा किट प्रदान की जाती है जिसमें मिफेप्रिस्टोन और मिसोप्रोस्टोल होता है। ये दवाएं पहले 8 हफ्तों ( पहली तिमाही में गर्भसमापन ) में सबसे अधिक सहायक होती हैं। डॉक्टर ठीक से समझाता है कि इन दवाओं का उपयोग कैसे किया जाए क्योंकि इन दवाओं को उचित तरीके से और डॉक्टर के मार्गदर्शन में लेना जरूरी है

नोटः डॉक्टर व्यक्ति को ठीक से जाँच करेगा,

गर्भावस्था की स्थिति की जाँच करेगा और फिर यह तय करेगा कि क्या करने की आवश्यकता है और उस व्यक्ति के लिये सबसे अच्छा क्या रहेगा। कुछ मामलों में सर्जिकल गर्भसमापन की आवश्यकता होगी (12 सप्ताह से पहले)। गर्भसमापन की प्रक्रिया अलग अलग व्यक्तियों पर निर्भर करती है।

प्रक्रियाः गोलियां लेने के लिए कदम गर्भसमापन की चिकित्सा प्रक्रिया

दिन 1ः मिफेप्रिस्टोन की एक 200 मिलीग्राम की गोली ली जाती है यह दवा गर्भावस्था को बढ़ने से रोकती है। मिफेप्रिस्टोन लेने के बाद कुछ लोगों को मिचली आने लगती है या खून बहने लगता है, लेकिन यह आम नहीं

है। संक्रमण को रोकने के लिए आपका डॉक्टर आपको एंटीबायोटिक भी दे सकता है। दिन 3 (24 से 48 घंटों के बीच)ः 200 मिलीग्राम की मिसोप्रोस्टोल गोलियां (कुल 800 एमसीजी) मौखिक या योनि रूप से दी जाती हैं।

गर्भसमापन की लागत/कुल खर्चा हमें ़918861713567 पर  whatsapp करें। यदि आपको अभी भी स्पष्ठ नहीं है, तो  कृपया हमें निजी सहायता के लिए व्हाट्सएप करें। यदि आप निजी अस्पताल से गर्भसमापन करवा रहे हैं तो कुल खर्चा 6 हजार से अधिक नहीं होना चाहिए। यदि आप सरकारी स्वास्थ्य क्लीनिकों में जाते हैं, तो यह आपको न्यूनतम कीमत पर प्रदान किया जाएगा। यदि हम आपको क्लीनिक से जोड़ते हैं तो

कुल खर्चा 3 हजार से कम होगा।

आप या तो मिसोप्रोस्टोल को तुरंत ले लेंगे, या पहली गोली लेने के 48 घंटे बाद तक – आपका डॉक्टर आपको बताएगा कि इसे कैसे और कब लेना है। यह गोली आपके गर्भाशय को खाली करने के लिए ऐंठन और रक्तस्राव का कारण बनती है। ज्यादातर लोगों के में, ऐंठन और रक्तस्राव आमतौर पर मिसोप्रोस्टोल लेने के 1-4 घंटे बाद शुरू होता है।

रक्तस्राव के समय खून के बडे थक्के या ऊतक के गुच्छे दिखाई देना सामान्य है। यह वास्तव में ऐंठन व अधिक रक्तस्राव के साथ होने वाली महावारी की तरह है, और गर्भसमापन की प्रक्रिया एक स्वतः गर्भपात के समान है। ध्यान देंः यदि आपको दूसरी दवा, मिसोप्रोस्टोल लेने के 24 घंटे के भीतर कोई रक्तस्राव नहीं होता है, तो डॉक्टर से सम्पर्क करें।

दिन 14 – 15ः गर्भावस्था के पूरी तरहा से समाप्त होने की पुष्टि करने के लिए एक व्यक्ति को गर्भसमापन उपरांत की जांच के लिए डॉक्टर की जरूरत होती है। डॉक्टर 15 दिनों के बाद अल्ट्रासाउंड जांच के लिए वापस आने की सलाह देंगे। फिर एक अल्ट्रासाउंड (पेट) कराएं क्योंकि यह पता

लगाना महत्वपूर्ण है कि क्या गर्भसमापन पूर्ण रूप से हो गया है और महिला सुरक्षित हैं। इन दवाओं का कोई साइड इफेक्ट नहीं है, लेकिन हमेशा डॉक्टर के मार्गदर्शन में लिया जाना चाहिए। यह देखना हमेशा बेहतर होता है कि क्लीनिक में गर्भसमापन की चिकित्सा समाप्ति करने के लिये प्रमाण पत्र प्रदर्शित किया है या नहीं। गर्भसमापन की सेवा लेने वाले व्यक्ति को झोलाछाप या अपंजीकृत डॉक्टरों से सावधान रहने की जरूरत है। आपके गर्भसमासपन के पूरा होने के बाद, जैसे जैसे घंटे और दिन गुजरेंगे आपको महसूस होने वाली ऐंठन और रक्तस्राव हल्का होना चाहिए। आपको शायद स्तन में अकड़ाहट भी हो सकता है, और उनमें से दूध जैसा पदार्थ भी स्राव हो सकता है। आरामदायक फिटिंग की ब्रा पहनने से आपको

अधिक सहज महसूस करने में मदद मिलेगी। अब तक किसी भी प्रकार की ठंड लगना, बुखार, या मतली को भी चले जाना चाहिए।  यदि आपको मिसोप्रोस्टोल (गोलियों का दूसरा सेट) लेने के 24 घंटे से अधिक समय तक मतली, उल्टी, दस्त या बुखार है तो तुरंत अपने डॉक्टर या स्वास्थ्य केंद्र पर सम्पर्क करें। यह एक संक्रमण का संकेत हो सकता है।

यह भी बहुत महत्वपूर्ण है कि 15 दिनों के बाद, एक बार स्वास्थ्य जांच के लिए जाना चाहिए,  यह सुनिश्चित करने के लिए कि गर्भ की समाप्ति पूरी हो चुकी है। इससे यह जांचने में मदद मिलती है कि गर्भाशय के अंदर कोई अवांछित तत्व तो नहीं है।

स्त्रोतः पलानड पैरंटहुड वेबसाइट

क्या भारत में गर्भसमापन कानूनी है?

हाँ।

और हां, यह कई विकसित देशों के विपरीत है जहां गर्भसमापन एक विवादास्पद विषय है जिसमें अक्सर राजनीतिक विचारधाराएं शामिल होती हैं। गर्भावस्था की चिकित्सय समाप्ति अधिनियम (मेडिकल टर्मिनेशन ऑफ प्रेग्नेंसी एम0टी0पी0) अधिनियम 1971 गर्भधारण के 20 सप्ताह तक गर्भावस्था की (एम0टी0पी0) की चिकित्सय समाप्ति की अनुमति देता है। यहाँ आपको क्या पता होना चाहिएः

गर्भावस्था के 12 सप्ताह के भीतर गर्भावस्था की चिकित्सय समाप्ति एक डॉक्टर की मंजूरी से की जा सकती है।

गर्भावस्था के 12 से 20 सप्ताह के बीच गर्भावस्था की चिकित्सय समाप्ति दो डॉक्टरों की सहमति से की जा सकती है।

एक महिला गर्भसमापन सेवा प्राप्त कर सकती है यदि-
  • गर्भावस्था के कारण यदि महिला का स्वास्थ्य (शारीरिक और मानसिक) खतरे में है।
  • यदि भ्रूण में असामान्यताएं हैं जो बाद में विकृति और जोखिम पैदा कर सकती हैं।
  • गर्भावस्था बलात्कार का परिणाम है।
  • गर्भधारण अनचाहा है और गर्भनिरोधक की विफलता का परिणाम है (गर्भनिरोधक के एक या अधिक तरीकों का उपयोग किए जाने पर भी गर्भावस्था हुई)। यह ध्यान रखना महत्वपूर्ण है कि यह खंड केवल विवाहित महिलाओं पर लागू होता है।
  • गर्भसमापन एक पंजीकृत चिकित्सिय अभ्यासकर्मी (आर0एम0पी0) द्वारा किया जाना चाहिए, जिसकी चिकित्सिय सेवाएं अधिनियम के तहत अनुमोदित हो, एक ऐसे स्थान पर जो अधिनियम के तहत अनुमोदित हो। कोई भी चिकित्सिय अभ्यासकर्मी गर्भसमापन नहीं कर सकता है।
अगर मैं 18 साल से कम हूँ तो क्या मैं गर्भसमापन करवा सकती हूँ?

हां, कम उम्र की लड़की गर्भसमापन करवा सकती है। जब तक कि कानून की शर्तें पूरी हो जाती हैं। इस तरह के परिदृश्य मेंहालांकि, लड़की के अभिभावक की सहमति अनिवार्यहै। एम0टी0पी0 अधिनियम अभिभावक को ‘‘एक नाबालिग या एक पागल व्यक्ति की देखभाल करने वाला व्यक्ति‘‘ के रूप मेंपरिभाषित करता है।

क्या एक अविवाहित महिला गर्भसमापन करवा सकती है?

भारत मेंगर्भसमापन, जबकि कानूनी, लेकिन महिला और भू्रण के स्वास्थ्य की चिंता से प्रेरित हैं। उदाहरण के लिए, गर्भनिरोधक की विफलता, विशेष रूप से विवाहित महिलाओं के लिए उल्लेखित एक षर्तहै। एक अविवाहित महिला, विवाहित की तरह, गर्भसमापन की सेवाएं स्वास्थ्य कारणों से प्राप्त कर सकती है और साथ ही अगर गर्भावस्था यौन उत्पीड़न के परिणामस्वरूप् है और महिला गर्भावस्था को आगे नहीं बढ़ाना चाहती है। हालांकि, वह महिला गर्भसमापन की सेवा की उम्मीद नहीं कर सकती है, अगर संभोग के दौरान कंडोम फट गया। क्या इसका मतलब यह है कि अविवाहित महिलाओं को भारत में गर्भसमापन की सेवायें नहीं मिलती है? शुक्र है कि ऐसा नहीं है।

महिला के लिए स्वास्थ्य संबंधी जोखिमों का नियम इस प्रकार हैः यदि गर्भावस्था की निरंतरता गर्भवती महिला के जीवन के लिये खतरा है या गंभीर चोट शारीरिक या मानसिक स्वास्थ्य के लिए जोखिम शामिल करेगी। इस प्रकार, यदि डॉक्टर अनचाही गर्भावस्था के मामले को देखता है, जिसमें गर्भवती महिला के मानसिक स्वास्थ्य को गंभीर चोट पहुंचे, तो वह गर्भसमापन को मंजूरी दे देगी/देगा।

क्या मुझे गर्भ समाप्त करवाने के लिए अपने पति की सहमति की आवश्यकता है?

नहीं. यदि आप 18 या अधिक वर्ष है, तो आपके किसी की भी सहमति की आवश्यकता नहीं है।

क्या 20 सप्ताह की सीमा के बाद गर्भसमापन की अनुमति नहीं है?

यह कानून के अनुसार नहीं है। हालांकि, यदि आवश्यक हो, तो आप अदालतों से संपर्क कर सकते हैं। इस तरह के अनुरोध के ठोस आधार होने चाहिए। पिछले साल, सर्वोच्च न्यायालय ने 20 सप्ताह की अवधि के बाद गर्भसमापन की अनुमति दी क्योंकि महिला को स्वास्थ्य जोखिम या भ्रूण के लिए गंभीर विकृति थी। सर्वोच्च न्यायालय ने अन्य अनुरोधों को भी अस्वीकार कर दिया था, वहां से महिला और भ्रूण के जीवन के लिए कोई जोखिम नहीं मिला।

गर्भसमापन के विभिन्न प्रकार क्या हैं?

दवाओं के द्वारा

आमतौर पर 7 सप्ताह के भीतरः एक एम0टी0पी0 किट का उपयोग किया जाता है जिसमें मौखिक रूप से लेने के लिए एक टैबलेट और योनि  द्वार में रखने के लिए चार टैबलेट होते हैं।

एक चिकित्सकीय गर्भसमापन दो हार्मोनल दवाओं के संयोजन का उपयोग करता है- एक एंटी-प्रोजेस्टेरोन और प्रोस्टाग्लैंडीन, जिसका उपयोग विभिन्न मार्गों के माध्यम से मुंह के माध्यम से, इंजेक्शन द्वारा इंट्रामस्क्युलर/नसों के द्वारा या योनि मार्ग से किया जा सकता है।

षल्य चिकित्सा/सर्जिकल माध्यम से

आमतौर पर 12 सप्ताह के भीतरःगर्भावस्था को सक्शन क्योरटेज नामक एक विधि का उपयोग करके समाप्त किया जाता है, जिसमें योनि में एक छोटी ट्यूब का डालना शामिल होता है जो एक सक्शन मशीन से जुड़ा होता है। इस विधि में गर्भावस्था को सांखकर निकाला जाता है।

आमतौर पर 12 सप्ताह और 20 सप्ताह के बीचः इस समय प्रयोग की जाने वाली विधि को फैलाव और निकासी कहा जाता है (डी एंड ई)। इसमें गर्भाशय को धीरे से खोलने के लिए गर्भाशय में गर्भाशय फैलाने वाली नलिका को डाला जाता है। एक बार जब यह गर्भाशय फैल जाता है, तो सक्शन ट्यूब और अन्य सर्जिकल उपकरणों का उपयोग करके गर्भावस्था को समाप्त कर दिया जाता है।

गर्भपात के बाद मैं क्या उम्मीद कर सकती हूं?

दर्द एक ऐसी चीज है जिसे हर कोई अलग तरह से अनुभव करता है। गर्भसमापन के तत्काल बाद खून बहता है। आपको कुछ दिनों के लिए ऐंठन हो सकती हैं। आपका डॉक्टर आपको कुछ राहत पाने के लिए दवाओं को लिखेगा।

योनि से किसी भी दुर्गंधयुक्त स्त्राव या बुखार की अनदेखी न करें ये एक संक्रमण के संकेत हो सकते हैं। थोड़ी सी भी असुविधा के लिए अपने डॉक्टर से मिलें। आप दो सप्ताह में अपने डॉक्टर से मिल सकतेहैं यह सुनिश्चित करने के लिए भी कि आप स्वस्थ्य हैं। खुद को महत्वपूर्ण बनाएं।

गर्भसमापन करवाने के बाद मैं यौन संबंध कब शुरू कर सकती हूं?

आपका शरीर आपकी जानकारी से ज्यादा स्मार्ट है। यह खुद से ठीक होगा। आपको पता चल जाएगा कि आप संभोग शुरू करने के लिए शारीरिक और भावनात्मक रूप से कब सहज हैं। कुछ डॉक्टर एक या दो सप्ताह के लिए परहेज करने की सलाह दे सकते हैं।

मुझे अगली माहवारी कब शुरू होगी?

आप गर्भसमापन के बाद तीन से छह सप्ताह के भीतर माहवारी आने की उम्मीद कर सकती हैं। गर्भसमापन के बाद अक्सर रक्तस्राव होता है, और कभी-कभी, यह रक्तस्राव एक या अधिक सप्ताह तक हो सकता है। यह रक्तस्राव आपके मासिक धर्म के समान नहीं है। गर्भसमापन के बाद आपकी पहली माहवारी आपके द्वारा अनुभव किए जाने की तुलना में अधिक गंभीर ऐंठन के साथ होने की संभावना हो सकती है।

लेखकः अनुराधा खुद को विचारक कहती है। एक कवि होने के अलावा, वह उन मामलों पर लिखती है जो उन्हें कथानक लगतें हैं। वह देहात की सह-संस्थापक हैं, जो एक आला कला ब्रांड है जो भारत की संस्कृति की सांस्कृतिक बेल्ट से कलाकारों के काम को सामने लाता है। वह चर्चा मंच लाउडस्ट के साथ भी जुड़ी हुई है और इसके पैनल चर्चाओंकोसंचालित करती है।

10 बातें जो आप भारत में कानूनी गर्भसमापन के बारे में नहीं जानते हैं।

भारत में गर्भावस्था की चिकित्सा समाप्ति अधिनियम 1973 ( मेडिकल टर्मिनेशन ऑफ प्रेगनेंसी/एमटीपी) या गर्भसमापन करने के बारे में बहुत सी गलत धारणा या स्पष्टता का अभाव प्रतीत होता है। बहुत सारी महिलाओं को यह पता नहीं है कि गर्भावस्था को समाप्त करना भारत में कानूनी है। जबकि महिलाओं के लिए यह जानना महत्वपूर्ण है कि गर्भसमापन कराने के संबंध में उनके क्या अधिकार है और क्या नहीं।

यहां उन 10 चीजों की सूची दी गई है, जिन्हें आप भारत में गर्भसमापन कराने के बारे में नहीं जानते हैंः

1. भारत में गर्भसमापन कानूनी है।

गर्भावस्था के बीस सप्ताह तक कुछ परिस्थितियों में गर्भावस्था का गर्भसमापन या गर्भावस्था की  चिकित्सा समाप्ति की अनुमति है। मेडिकल टर्मिनेशन ऑफ प्रेग्नेंसी एक्ट 1971 के अनुसार, गर्भावस्था को कुछ परिस्थितियों में समाप्त किया जा सकता है। जिनमें निम्न परिस्थितियां शामिल है

  • बलात्कार
  • गर्भवती महिला के स्वास्थ्य के लिए शारीरिक या मानसिक जोखिम
  • विवाहित महिलाओं के मामले में गर्भनिरोधक की विफलता
  • भ्रूण/बच्चे को किसी भी प्रकार की विकलांगता की संभावना
2. महिला को गर्भसमापन के लिए हां या ना कहने का अधिकार है।

गर्भसमापन कानूनी होने के बावजूद, एमटीपी अधिनियम गर्भावस्था को मांग पर समाप्त करने का अधिकार प्रदान नहीं करता है, महिला जबरन गर्भसमापन को ना कहने का विकल्प चुन सकती है। महिला को गर्भावस्था जारी रखने और बच्चा पैदा करने का अधिकार है। कोई भी उसे गर्भसमापन कराने के लिए मजबूर नहीं कर सकता। गर्भावस्था की चिकित्सय समाप्ति अधिनियम 1973 के अनुसार ऐसा करना एक दंडनीय अपराध है!

3. गर्भसमापन करवाने के लिए आपको केवल आपकी सहमति की आवश्यकता होती है।

यदि आप एक गर्भवती महिला हैं जो गर्भसमापन करवाना चाहती हैं, तो याद रखें कि गर्भसमापन करवाने के लिए केवल आपकी सहमति की आवश्यकता होती है। यदि आपकी आयु 18 वर्ष से अधिक है, तो आपको गर्भसमापन करवाने के लिए किसी और की अनुमति की आवश्यकता नहीं है। यदि किसी अस्पताल में डॉक्टर या अन्य कर्मचारी आपके माता-पिता या पति की सहमति के लिए पूछते हैं, तो उन्हें बताएं कि यह आपका शरीर और आपका अधिकार है।

4. गर्भावस्था के 20 सप्ताह तक गर्भावस्था को समाप्त किया जा सकता है।

गर्भावस्था की चिकित्सय समाप्ति अधिनियम किसी भी गर्भावस्था को गर्भावस्था के 20 सप्ताह के भीतर समाप्त करने की अनुमति देता है। हालांकि, जनवरी 2017 में, सर्वोच्च न्यायालय ने एक बलात्कार पीडिता को 24 सप्ताह में अपनी गर्भावस्था को समाप्त करने की अनुमति दी थी क्योंकि भ्रूण को सिर नहीं विकसित हुआ था। यह ध्यान देने योग्य है कि 2014 में तैयार एक संशोधन में गर्भावस्था की समाप्ति सीमा को वर्तमान 20 सप्ताह से 24 सप्ताह तक बढ़ाने की मांग की गई थी।

5. गर्भावस्था की हर समाप्ति भ्रूण हत्या नहीं हो सकती है।

गर्भावस्था की समाप्ति एक भ्रूण हत्या केवल तब है अगर गर्भसमापन लिंग निर्धारण परीक्षण के बाद किया जाता है। पी0सी0पी0एन0डी0टी0 अधिनियम 1994 में लिंग निर्धारण परीक्षणों के आधार पर कन्या भ्रूण हत्या को रोकने के लिए लागू किया गया था। यदि यह साबित हो जाता है कि गर्भसमापन लिंग निर्धारण परीक्षण के कारण ही किया गया है तो यह दंडनीय अपराध है।

6. 12 सप्ताह की गर्भावस्था के दौरान लिंग निर्धारण संभव नहीं हो सकता है।

यहां लिंग निर्धारण परीक्षण से जुडी बात यह है, कि पी0सी0पी0एन0डी0टी0 अधिनियम लिंग निर्धारण परीक्षण करने वाले तकनीशियन को दंडित करता है। आमतौर पर, गर्भधारण के 12 सप्ताह के भीतर भ्रूण का लिंग निर्धारित नहीं किया जा सकता है। इसलिए 12 सप्ताह की गर्भावस्था के भीतर किए गए गर्भसमापन को लिंग चयन के साथ नहीं जोड़ा जा सकता है। जो बताता है कि, एक महिला को लिंग चयन के लिए मजबूर करना एक दंडनीय अपराध है।

7. केवल एक पंजीकृत चिकित्सिय अभ्यासकर्मी (त्महपेजमतमक उमकपबंस च्तंबजपवदमत ) ही गर्भसमापन कर सकते है।

किसी भी गर्भवती महिला को गर्भसमापन एक पंजीकृत चिकित्सिय अभ्यासकर्मी द्वारा ही करवाना महत्वपूर्ण है। जब आप गर्भसमापन करवाना चाह रहे हों तो यह एक बहुत छोटी बात की तरह लग सकता है लेकिन यह एक महतत्वपूर्ण बात है जिसे बहुत गंभीरता से लिया जाना चाहिए, यह देखते हुए कि असुरक्षित गर्भसमापन कई जटिलताओं को छोड़ सकता है। एम0टी0पी0 एक्ट किसी भी डॉक्टर के लिए पंजीकृत चिकित्सिय अभ्यासकर्मी बनने की आवश्यकताओं को निर्धारित करता है। इसमें यह सुनिश्चित करने के लिए कठोर प्रशिक्षण के कई स्तर शामिल हैं कि डॉक्टर गर्भसमापन करने के लिए योग्य हैं। इसलिए यह जरूरी है कि केवल एक पंजीकृत चिकित्सिय अभ्यासकमी से ही गर्भसमापन करवाया जाए।

8. गर्भसमापन केवल एक सरकारी अस्पताल या जिला स्तरीय समिति द्वारा अनुमोदित स्थान पर ही किया जा सकता है।

गर्भसमापन करने के लिए पंजीकृत चिकित्सिय अभ्यासकर्मी की आवश्यकता के साथ ही, यह भी आवश्यक है कि गर्भसमापन सरकार द्वारा अनुमोदित अस्पताल में ही करवाया जाये। एक गर्भावस्था केवल एक सरकारी अस्पताल या इस उद्देश्य के लिए स्थापित एक जिला स्तरीय समिति द्वारा अनुमोदित अस्पताल में समाप्त करवाई जा सकती है। यदि आप गर्भसमापन कराने के बारे में अनिश्चित हैं कि गर्भसमापन कहां पर होगा तो असुरक्षित गर्भसमापन के कारण उत्पन्न होने वाली किसी भी जटिलता से बचने के लिये नजदीकी सरकारी अस्पताल में जाएं।

9. गर्भपात एक अधिकार नहीं है।

भारत में गर्भसमापन करवाना कानूनी हो सकता है, लेकिन यह एक ऐसा अधिकार नहीं है जो महिलाओं के पास है। इसका क्या मतलब है? इसका मतलब है कि आप मांग पर गर्भसमापन नहीं करवा सकते हैं, जिसका अर्थ है कि एक महिला डॉक्टर से गर्भसमापन करने के लिए नहीं कह सकती है। यह केवल ऊपर वर्णित कारणों में से किसी एक या अधिक के लिए प्राप्त किया जा सकता है।

10. डॉक्टर किसी भी महिला पर गर्भसमापन करने से मना कर सकते हैं।

यह जानते हुए कि गर्भसमापन भारत में एक अधिकार नहीं है, कोई भी डॉक्टर गर्भावस्था को समाप्त करने से इनकार कर सकता है। उदाहरण के लिए, महिला अपनी गर्भावस्था को समाप्त करने के अनुरोध के साथ ही अपनी शारीरिक या मानसिक स्वास्थ्य के लिए जोखिम का उल्लेख कर सकती है। हालांकि जब तक डॉक्टर यह नहीं देखते कि यह वास्तविक जोखिम है, वे गर्भावस्था को समाप्त करने से इनकार कर सकते हैं।

इस मुद्दे पर अधिक सुनने के लिए, हमारे पॉडकास्ट की जांच करें जहां जैस्मीन जॉर्ज, एक वकील और यौन और प्रजनन स्वास्थ्य अधिवक्ता एमटीपी अधिनियम पर चर्चा करते हैं।

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!

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!