Women’s reproductive rights in general, and abortion in particular, have been the subject of intense debate globally. Even in countries where the law permits abortions women battle stigma, bias, lack of awareness and information, all of which result in restriction of access to safe abortion.
Almost 48 years after abortion was legalised in India, a majority of women continue to lack access to safe abortion care. Unsafe abortion is the third leading cause of maternal mortality in India. Every day 10 women die in India due to unsafe abortion-related causes and many more suffer from morbidities such as pelvic inflammatory disease and infertility, which are related to unsafe abortion practices – ranging from home remedies to inserting sharp foreign objects into the cervix.
It is estimated that 15.6 million abortions take place annually; however, there are just 60,000 to 70,000 providers who can legally provide abortions under the Medical Termination of Pregnancy (MTP) Act, woefully inadequate for a country of our size, and most of them centred in urban areas.
The MTP Act 1971, a liberal law at the time, allows women to undergo abortion up to 20 weeks, subject to certain conditions. Unfortunately, a half century later, the MTP Act has not kept up with the changing discourse on sexual and reproductive rights and advancement in medical technology and remains stuck in a time warp. A draft amendment was put out in 2014, which among other things sought to make first trimester abortion a right and expand the provider base. Unfortunately, the 2014 amendments have not seen the light of day.
The approval of drugs – Mifepristone and Misoprostol – for early abortion in 2002 followed by the approval of combipack in 2008, dramatically changed the way women access abortion care in India. A 2015 study estimated that 81% of all abortions in India used medical methods. More importantly, severe and life-threatening complications of unsafe abortions which doctors used to see till the nineties, dropped dramatically.
Sadly for women in this country, access to these lifesaving drugs is becoming a major issue. The Pratigya Campaign for Gender Equality and Safe Abortion’s 2018 study among 1008 chemists in four states shows that that these drugs are vanishing from markets. The reason? Overregulation led by a misplaced understanding that reducing access to MA drugs will help arrest the declining child sex ratio.
MA drugs are indicated for use up to nine weeks gestation. Sex determination, using the most common and affordable diagnostic tool – ultrasonography – is not possible during this period. Ultrasound can determine the sex of the foetus only at 13-14 weeks (early second trimester). An overwhelming majority of abortions in India, estimated upwards of 85%, occur in the first trimester.
Women’s right and access to abortion, which the MTP Act enables, has somehow become entangled in the fight against gender-biased sex selection. As a result, chemists claim they face additional scrutiny if they stock MA drugs. They are informally told not to sell MA drugs, keep copies of prescriptions and in some cases, keep track of the identity of the purchaser – a clear violation of the MTP Act which assures women confidentiality. There is an urgent need to clear the prevailing misunderstanding among drug regulators and health officials about MA drugs and sex selection.
The other concern that fuels restricting availability of MA drugs is the perception that unsupervised use can harm women’s health. There is enough evidence to suggest that the risks to women’s health and life are minimal even if MA drugs are used without supervision. World Health Organisation’s 2019 edition of ‘List of Essential Medicines’ deleted an advisory for MA drugs found in the 2018 list which said “should be used under close medical supervision”. In fact WHO recommends that general physicians, nurses, auxiliary nurse mid-wives and in some circumstances AYUSH doctors can manage provision of medical abortion. Many countries, including Nepal and Bangladesh, allow these cadres of health care providers to offer medical abortion.
There is no doubt that approval of medical abortion and access to MA drugs has made and continues to make a significant difference to the lives of millions of women and gives them an option to exercise their sexual and reproductive rights and choice. Unfortunately that right and choice seem to be under threat due to MA drugs vanishing from chemist shelves. If proactive steps are not taken to change the situation, millions of women would be forced to seek unsafe abortions risking their health and lives.