An adult abortion seeker doesn’t need a husband or partner’s permission to get an abortion, and can terminate a pregnancy up to 24 weeks. And yet, 67% of the abortions in the country are unsafe.

Stylised image of a woman against the backdrop of medical staff inside a hospital
Delve Health Monday, January 02, 2023 - 11:37

When Dr Suchitra Dalvie was a trainee back in 1995, she was assisting in the surgery of a woman who had internal injuries following an abortion. “She had sepsis due to sticks being inserted in her uterus for termination of pregnancy,” Dr Suchitra, a gynaecologist who is now the Coordinator at the Asia Safe Abortion Partnership tells TNM. This is neither an isolated incident nor have things changed much in the last 25 years. “While such cases may be rarer in cities now, they are very much present in rural and semi rural areas due to lack of access to safe abortion services”, she says. Some studies estimate that at least eight women die in India due to an unsafe abortion every single day — 67% of abortions in the country between 2007 and 2011 are believed to have been unsafe. “Young women aged 15–19 were at the highest risk of dying from an abortion-related complication,” according to the United Nations Population Fund’s State of World Population Report 2022.

All this in a country that has one of the most liberal on-paper abortion laws in the world. The Medical Termination of Pregnancy (MTP) Act, which was enacted in 1971, was brought in with the goal of controlling the population of the country. While the intended objective wasn’t women’s rights, with the amendments made to the law and precedents set by the judiciary, India’s abortion law is effectively progressive, allowing legal — and safe — abortions up to 24 weeks into a pregnancy. In a world where developed nations like the United States of America are rolling back abortion rights, the legal regime in India is aspirational for many countries. 

So why is there such a discord between the law and reality? Firstly, there is little awareness of the law among citizens fed on a pop-culture and religious diet of ‘abortion-is-sin’. Secondly, the implementation of the law lies in the hands of healthcare providers, and a large number of them view abortion as a ‘bad thing’, not as a right or a value-neutral medical procedure. 

Dr Suchitra explains that while India’s abortion laws have been liberal, the Indian Penal Code (IPC) criminalises ‘causing miscarriage’. In essence, the MTP Act decriminalises abortions when performed by doctors, and it is heavily dependent on the liberal, sensitive interpretation of the law by doctors. “When our collective morality itself is paternalistic and eugenics-based, all kinds of socio-cultural prejudices interfere with the execution of the law. In such situations, the right of the abortion seeker is hardly given any importance,” she says.

Doctors as guardians of patriarchy

The World Health Organisation (WHO) defines an unsafe abortion as ‘a procedure for terminating an unintended pregnancy, carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards or both’. In India, this translates to herbal concoctions and physical methods that are at best ineffective and at worst, fatal. 

One of the recurring reasons why people opt for an unsafe abortion is the moral policing they face at hospitals and by doctors. “After my first child was born, I went to the doctor for a postpartum check-up,” says Sowmya Anilkumar, a 29-year-old data scientist based in Chennai. “The doctor told me that since I had a C-section, I should not get pregnant again for at least two-and-a-half years. She also said that if I went back to her ‘begging’ for an abortion before this time period, she would not help because ‘they don’t do such things’,” she recalls. The sense of humiliation and shock that she felt at the moment held her back from responding to the doctor. “What is the point of having a legal right if your doctor herself shames you for choosing it when you want to? In such cases, where else will you go to ensure you have a safe abortion?” she asks.

The moral policing that pregnant individuals face was witnessed first hand by TNM reporters Bharathy Singaravel and Nidharshana Raju recently, at no less than a government hospital in Chennai when they went to investigate the availability of emergency contraceptive pills at the Government Kasturba Gandhi Hospital for Women and Children. While our reporters were waiting at the hospital and were facing humiliation from the doctors and staff there, they encountered a woman — married and with two children — who found that she was 10 weeks pregnant while undergoing some tests. She was told by two doctors, a couple of nurses, and a counsellor, that she must get the permission of her husband to abort the pregnancy. They tried to convince her that this is the law (which is false) and that if she wants to have another child sooner or later, she might as well have it now.

“At a very well-known private hospital in Chennai’s Mylapore, there is a huge board which says ‘MTP will not be done here’,” says Archanaa Seker, a Chennai-based writer, researcher, and rights activist. “Another board also says ‘No sex-selective diagnostic procedures’. This is misleading because one is the law and one is prejudice. So when a person comes to this hospital, they may think both are illegal,” she explains. 

“Those who can read and understand the law and keep themselves updated with evolving legal interpretations know that abortion is a right. But this information is hardly accessible to people across strata in our country. Awareness is skewed even among healthcare providers, and most people read the law from a place of personal and cultural prejudice. This creates a gap in the understanding of the law itself. Ignorance of the law and institutional prejudice leads to abuse of power because nobody in power is held accountable to provide abortions as prescribed by the law,” Archanaa says.

“The cultural question of ‘killing something’ arises, and there is an assumption that abortion is morally wrong, and therefore illegal. This interferes with an objective understanding of the law, resulting in the denial of medical care to abortion seekers even by doctors. The aspect of the person’s mental health is also entirely neglected in this conversation,” Archanaa observes.

Read: The dehumanising ordeal of accessing ECPs at a Chennai Govt hospital

Unsafe abortion, or an unwanted child

Abortions rights activists point out that such stigmatisation of abortion does little to stop abortions — all it does is push women to opt for unsafe options. In 2015, The Lancet reported that out of the 1.56 crore abortions conducted in India, 1.23 crore were performed outside health facilities. The other option in the absence of a safe abortion is going through with an unwanted pregnancy and having a child without being prepared for one. 

Brinda (name changed), a researcher based in Kerala, says that her sister went through with a second pregnancy because the doctor brainwashed her into believing that abortion was sinful. “The doctor told my sister about how her own son was childless and deeply pained and was in the process of adopting a child at that point. She used such examples to convince my sister, who is a medical professional herself, that she was lucky to have conceived a second time. My sister had the baby, but she does not have a proper support system and struggles every day,” Brinda says.

With motherhood being considered the most important biological and social role of a woman in the country, there is little pushback to the moral policing that’s widely practised by healthcare providers. Issues like maternal health, postpartum depression, and bodily autonomy are seldom addressed.

Shalini (name changed), a mother of two, recalls her experience with aborting a complicated pregnancy in 2014. “My doctor was a committed Catholic,” she tells TNM, “The doctor suggested that we go ahead with the pregnancy despite natal experts confirming that it may be dangerous for me since the placenta was not in a healthy condition. She said I could avail multiple surgeries post-delivery, though chances of the baby surviving were below 10%. She reprimanded our choice to abort with anger and warned us that we were going against god’s will. My husband and I decided to abort the pregnancy anyway, but this doctor’s behaviour still triggers me when I lie down for checkups.”

Marginalisation worsens access

Dalit writer and activist Shalin Maria Lawrence notes that in Chennai, child marriage rates in marginalised communities are high despite the demography being urban. “Women don’t know abortion can be done or that they have the option to leave a toxic relationship,” Shalin says, “And so young girls get pregnant in relationships and think they must have a child. If they go to any hospital saying they are pregnant out of wedlock, they are traumatised. They end up marrying the person, or going to medical shops and procuring abortion pills without a prescription and end up being sick due to unsafe, unsupervised abortions. Some develop fibroids, suffer severe bleeding, or even die due to half abortions. This has been happening for the past 30 years.”

Shalin adds that in rural areas sex-selective abortions are done in unsafe circumstances, especially in Bahujan households, despite sex selection being illegal in the country. “Doctors see this as a money-making endeavour, and don’t care for the woman’s health. Some people also take herbal medicines and other concoctions to induce abortions and fall sick or even die. Such deaths are not recorded or reported properly,” she says. 

Additionally, rural areas also face the problem of not having enough hospitals and medical practitioners. The Indian Rural Health Statistics 2019-20 said that there is a 70% shortfall of obstetricians and gynaecologists in rural areas.

Public health doctor and disability rights activist Dr Aishwarya Rao says that disability is another important intersection that is very rarely addressed in the abortion debate. “Especially in the case of speech and hearing impaired individuals, it is difficult to communicate with doctors even in regular health checkups. The healthcare system is not equipped to address this and I think a lot of bad behaviour from doctors and medical staff also comes from ignorance and provider system incapabilities,” says Dr Aishwarya, a person with disabilities herself. 

“Women with disabilities are not a homogenous group,” Dr Suchitra says, “So we need to also look at how they can begin with basics like communication. How many of our hospitals even provide information in sign language and Braille? So how do we expect abortion seekers with disabilities to navigate this system and access abortions safely?” 

Sex and the MTP

If we want the MTP laws to work effectively, we must look at sex, contraception, healthcare, and morality in connection to each other, says Archanaa. “Until we take the shame out of sex, we will not be able to take the stigma out of abortion,” she says. “Sex is a human need. Young people are sexually active and we cannot gatekeep culture and deny the existence of desire,” she says. 

Dr Suchitra agrees. “To ensure safe abortions, we need comprehensive sexuality education in schools so that young people understand their bodies and have conversations about myths and misconceptions. We need to speak about men taking equal responsibility and participating in contraception and sexual healthcare. We must make medical abortion pills more freely and evenly available, preferably through telemedicine,” she explains, stressing the importance of state intervention in this regard.

This reporting is made possible with support from Report for the World, an initiative of The GroundTruth Project.

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