Despite abortion being legal in India for almost five decades, unsafe abortion continues to be the third largest cause of maternal mortality and accounts for 8% of all maternal deaths in India. Ten women die every day, and thousands more face serious and permanent injuries annually due to unsafe abortion-related causes. Most deaths caused by unsafe abortion are, however, preventable. With the advent of newer and simpler technologies, induced abortion is now a very safe and simple medical procedure, which can save the lives of millions of women.
A recent study published in Lancet Global Health estimates that only 22% of the 15 million abortions that occur in India every year take place in a public or private health facility, and are performed by trained personnel, whereas the remaining 78% of abortions happen outside health facilities. We need to identify the reasons as to why 78% women access services outside the facilities, and how they can be included in the ambit of the formal healthcare system. Many barriers force women to access abortion services outside the formal healthcare system, such as lack of access to health facilities providing abortion services, lack of awareness about abortion legality, especially among rural women, the stigma associated with abortion, and the costs incurred in seeking abortion services.
Abortion provision in India is governed by the Medical Termination of Pregnancy (MTP) Act, 1971, which allows for termination of pregnancy until up to 20 weeks of gestation for a broad range of conditions. India was one of the first 15 countries to legalize abortion services in 1971. When this law was passed, the only available technology for termination of pregnancies was dilatation and curettage (D&C)—now an outdated invasive medical procedure. The safety provisions in the law, including provider definition, training requirement and opinion, were defined keeping women’s safety the entire point of this technology. The then progressive act has lost its relevance today given technological advancements. Newer and safer technologies have made abortion a very safe out-patient medical procedure, and these technologies do not require specialist doctors.
Therefore, the MTP Act allowing only allopathic doctors with specialization in obstetrics and gynaecology, or general practitioners who have undergone a 12-day certification training to legally provide abortion services, is limiting as it is estimated that fewer than 90,000 doctors in India meet the criteria today. This is woefully inadequate in providing for the 15 million abortions occurring every year. In addition, the presence of these providers is heavily skewed towards urban areas, leaving majority of rural women without access to an approved provider.
While a majority of the Indian population lives in rural areas, safe abortion services are not accessible in these areas due to the lack of trained providers, and due to various individual and social factors. Research conducted by Ipas Development Foundation (IDF) among rural communities in Bihar and Jharkhand, published in The BMJ 2017, indicates that not even 30% women know that abortion is legal in India and, of them, only 2% know that abortion is legal up to 20 weeks. The awareness levels in the rest of the country is also abysmally low.
Further, the stigma around abortion compels women to choose less safe pathways for termination of pregnancy, when they should have access to safe, free-of-cost, non-stigmatized abortion services at public health facilities. A study by IDF published in BMC Public Health 2012 indicates that as many as 58% women feel guilty when they think about abortion and consider it a sin.
Abortion care in the private sector is way beyond what most Indian women, especially in rural areas, can afford. Although the public sector provides services free of charge, these are not adequately decentralized and available closer to the rural communities. The study published in BMC Health Services Research 2017 also indicates that women on an average travel 26 km to reach a secondary or tertiary level facility to seek abortion services. The out-of-pocket costs of travel, work-day loss, accompaniment, etc., in reaching distant public sector facilities can significantly burden families.
Abortion services need to be decentralized to the last mile, so that they are accessible to women closer to the community. One way to strengthen access to safe abortion services is to speed up the amendments to the MTP Act and allow mid-level providers who are closer to the community to provide abortion. This would significantly help expand the cadre of providers that can offer abortion services. However, this solution in itself is inadequate as there is a need to holistically address other sociocultural barriers, such as lack of awareness of abortion legality, limited understanding of the risks of unsafe abortion, and the myths, misconceptions and stigma associated with abortion.
We know what needs to be done to make safe abortion a reality for all Indian women. The judiciary, policy makers, medical fraternity and civil society organizations must attempt to address the current barriers women face, and ensure that safe abortion services are delivered in a respectful and non-judgmental manner. Let us hold ourselves accountable for the needless deaths and disabilities faced by women in a liberal legal environment.
Vinoj Manning is the Executive Director of Ipas Development Foundation.