These legal and social barriers to abortion also exist within an inadequate healthcare system that is understaffed and ill-equipped. The MTP act only allows abortion in hospitals or in settings approved by the government. The act also only allows gynaecologists with three years of experience, and MBBS doctors with specific training, to conduct the termination.
“There are around 30,000-40,000 OB-GYNs in India and though we have about 700,000 MBBS doctors, only about 100,000 are trained to provide abortion services,” said Vinoj Manning, the chief executive officer of Ipas Development Foundation, the non-profit that conducted the survey in Assam and Madhya Pradesh, “So we are looking at a cadre of around 140,000 service providers who can terminate pregnancy as per the act.”
In rural areas, there is a nearly 70% shortage of obstetricians and gynaecologists at community health centres.
The stigma, legal issues and the shortage of medical providers mean that most abortions conducted in India are illegal. As per a 2018 Lancet study, nearly 78% of the 15.6 million abortions in 2015 were conducted outside of health facilities, making them illegal as per the MTP act. However, most (73%) of these abortions are done by injesting abortion pills that can be acquired without a prescription. While this method is not completely safe – medical supervision is advised – experts say it is relatively safe.
For early pregnancies upto 12 weeks, there is no reason why somebody other than a doctor cannot supervise pill-based abortions, said Dalvie. “Nurses are also trained on how to check for pregnancy, so they do have that kind of an experience. There is no reason why a reasonable amount of supported self-management should not be possible.” The World Health Organization also recommends self-administration of medical abortion pills till 12 weeks of pregnancy.
Despite the safety of these pills, drug controllers across the country are trying to clamp down on their supply because of concerns that they will be used to abort unwanted female foetuses, violating the PCPNDT act, said Chandra of NLSIU.
“Our laws are completely behind global standards. We require everything to be under the supervision of doctors and we require it to be at facilities. Even if the doctor is prescribing the pills for consumption at home, there are all sorts of facilities that the doctor is required to maintain, all sorts of qualifications that the doctor is required to have,” she said.
The shortage of qualified doctors impacts another aspect of access to abortions. Women who are denied abortions often approach High Courts and the Supreme Court. The courts then constitute a medical board consisting of doctors with multiple specialties for advice.
In a country short of specialised doctors, this often entails multiple trips to distant tertiary centres. A lawyer told the authors of the NLSIU study about a client who had to withdraw her plea for a late abortion because the board demanded several visits though the family lived far from the hospital.
“Every day, [the Board] would only do one examination and they kept asking them to come back,” said the lawyer, “[They] were so fed up, they had called me about it, and at the time I [told them] “Listen you have to, I do not know what else to do” –and then eventually they stopped going to the board and they stopped answering my calls. So, the case had to be withdrawn because I had no instructions.”
Doctors also tend to be judgemental about women seeking an abortion: a senior gynaecologist told the authors of the study this: “We leave our big OPD [out-patient department] aside and concentrate on one woman who had forgotten that she had a child [sic] inside her for 4-5 months. We internally decided [that] she can wait for 3 more days for the board to respond.”
For safe abortion to become a reality for women, three aspects need to be addressed said Manning. “One is to get providers at the periphery trained, the second is to improve awareness about the legality of abortion and create pathways for women to come and get abortion services and third is to find ways to normalise abortion so that the stigma is not there,” he said.
(*Name changed to protect identity)