Trigger Warning: This article mentions death and rape.
5 Billion people around the world cannot get surgery when they need it. Surgery covers a wide range of diseases and populations. Access to obstetric surgeries has helped in reducing maternal mortality and improving the health of women globally. Yet, people in many low- and middle-income countries, including India, cannot access many components of emergency and essential obstetric and gynecological care. Access to safe abortion is one such aspect that is also a major public health concern in India. In 2015, India witnessed 2.2 million (14%) surgical abortions. However, nearly 800,000 abortions were carried out using unsafe methods. This clearly highlights that despite progressive laws, unsafe abortions are still performed in India.
In a country where millions of women require abortion services, it is important to note that encouraging and enabling access to the service is a small but significant step. Abortion is a health issue that has legal, operational, cultural, and social barriers and implications. Thus, it is important to look at it from a broader perspective and not just consider it a healthcare provision issue. Abortion care is a social issue.
It is important to bring to the lived experiences of people seeking abortion to the forefront. We need to encourage people-centric care where experiences matter as much as numbers. Thousands of women came forward to share their intimate personal accounts, as part of the Khud Se Pooche (ask yourself) campaign that focused on encouraging women to share their experiences in a safe space. A space where their experiences are not dismissed and where they could define what dignity in healthcare could look like.
Here we share the stories of some women who were put at risk because of the inadequacy of the health system and society and the thoughts of healthcare providers who have witnessed how inadequacies lead to injustices.
Different Journeys, Experiences, and Realities
The journey of finding out about unwanted pregnancies is a lonely one for most women. As they miss their periods, the ones with access to the internet look up online, others ask around, and fear starts seeping in right there. Very few would be able to talk to their partners, and even fewer would consult a medical professional for help.
We asked young people whether they had heard of anyone around them who had had an abortion. Following a period of complete silence, one person raised his hand and told about his friend who had once missed her periods but did not know what to do. “ASHA didis (community health workers) are like our mothers, we can’t go to them with such issues. The entire village will know. My friend went away from the village as she had heard Woh saaf kar dete hain (they clean it quickly). It’s not safe, but nobody came to know about it.”
Dr. Sarin Varghese, a gynecologist currently working in a rural hospital in Bihar, says, “Abortions are generally handled by untrained dais and local informal healthcare providers. It's easier for them as abortifacient drugs are more readily available than contraceptives. With no prevalent contraceptive practices, having an abortion is the only means left for an unwanted pregnancy.” According to Dr. Varghese, her hospital commonly treats women with life-threatening complications related to unsafe abortion practices. “We have had women dying due to serious infection following unsafe abortions,” told Dr. Varghese.
Very few women are able to seek medical help. And when they do, they are filled with fear of being judged by their healthcare providers. This sometimes even makes them continue with their pregnancies as the social restraints bar them from getting an abortion. A 20-year-old, unmarried girl from Maharashtra shared, “I got pregnant last year. I went to my gynecologist to ask for termination. She called her junior doctors inside and went to give me a moral lecture about how I am ruined, and how my future husband will react. I cried the entire time.”
“I was raped, when I was 18 (now I am 20) by a relative and was a month pregnant. I was shamed for wanting to abort the child. I was told I should make rational choices in life, and whatever happened, has happened. It doesn’t mean I should give up. This was told by the doctor herself,” shared a lady who wishes to stay anonymous.
A 28-year woman in Delhi looked up all possible non-judgemental gynecologist recommendations for Delhi and took an appointment to meet one in Vasant Kunj. Pregnancy was no older than 4 weeks. After seeing the ultrasound, the doctor asked, “Why don’t you get admitted tomorrow [at a leading hospital] for a surgery package that costs 30,000-50,000 Rs or choose pills that cost 3-5K INR?” She was left confused as the conversation focused on expensive packages for surgery rather than building trust in what would be best for her body.
Not just poor access to care, but poor access to dignified care has made the situation worse. A doctor from Bihar shared that when a woman comes for an abortion, she is asked to first discuss it with her family. Another woman shared her story of being denied an abortion because she went with her sister and not her husband. She said that the doctor thought she was lying about having a husband. He screamed at her and asked her to come back with the husband.
In a rush to reduce instances of abortion and promote family planning methods, many women were told that they can only get an abortion done if they get an IUD implanted, especially women from marginalized backgrounds. In one instance, a woman told us that the doctor saw her Muslim name and said, “You keep reproducing as you don’t use contraception. This time you better get an IUD implanted.” The situation is worse for unmarried women with unwanted pregnancies as accessing safe abortion is worse for them due to socio-cultural barriers.
The Complexity of The Issue and The Way Forward
“Adding to the fire is prenatal sex determination,” says Dr. Varghese.
The Pre-Conception and Pre-Natal Diagnostic Techniques (PCPDNT) Act exists to prohibit pre-natal gender determination. As long as the medical practitioner is in accordance with the Medical Termination of Pregnancy Act, abortion services should be provided. However, due to suspicion of sex-selective abortion, healthcare workers often dissuade women from getting an abortion, even when life-saving.
Lack of awareness of how to use contraceptive pills is another significant barrier to good reproductive health. “The widespread availability of over-the-counter abortion pills without regulations and with an unaware community increases the risks of incomplete abortions and its complications,” said Dr. Tobey Ann Marcus, an Obstetrician in Community Health and Development Department at CMC Vellore.
Due to improper use of contraceptives, doctors discourage their use. However, role the broader public health system has a role in educating the women on safe use of these pills. As highlighted by WHO, self-assessment, and self-management of medical abortion care, with proper knowledge, information, and healthcare access can be empowering for women. Lack of this is the root cause of unsafe abortion as women who either do not use pills properly or do not use it at the right time end up requiring a surgical abortion. Lack of access to good quality abortion care thus pushes them toward unsafe abortion practices. According to Dr. Tobey, “The use of contraceptive pills can be made safer by proper education and awareness.”
One of the most important disparities in abortion access is the urban-rural disparity. Generally, urban areas offer better access to abortion services. But according to Dr. Tobey, there are two sides to this. “There are places which are very morally ‘correct’ and do not offer terminations of pregnancy for any other reason other than major anomalies in the unborn baby. Then there are many other hospitals and practitioners who freely offer abortion services with no questions asked.”
According to Drs. Tobey and Varghese, improving family planning services will help in reducing unwanted pregnancies and unsafe abortions. Abortion awareness camps and early initiation of sexual and reproductive health education will help in destigmatizing abortion not just in the general public but also among healthcare providers, according to Dr. Basalel Benny Mathew, a post-graduate resident in Obstetrics and Gynecology at CMC Vellore.
Lastly, access to quality healthcare needs to be prioritized. “Even when a safe procedure like manual vacuum aspiration (MVA) exists, women in rural areas are still undergoing dilatation and curettage to abort their pregnancies. This leads to heavy bleeding, a complication rural areas are not equipped to manage due to lack of blood banks,” mentions Dr. Basalel, sharing his experience from his two years of service in rural Jharkhand.
All these experiences are telling of the barriers to and stigma in accessing abortion services in India, including those to lack of awareness related to reproductive health, and access to good quality healthcare services among other sociocultural barriers. To influence health outcomes, we need to consider and actively engage with factors beyond medicine, like sociocultural norms that affect health. Abortion care needs to center around a person’s life’s realities, challenges, local contexts, and a broader set of forces that determine decisions around reproductive and sexual health.
Gurpriya Singh is a Senior Campaigner at Purpose, she comes with over 8 years of experience working with young people and women on sexual and reproductive health and rights. Gurpriya is part of the Khud Se Pooche community, to make dignity in healthcare an everyday, open and safe conversation.
Parth Sharma is a physician, public health researcher, writer, and the founder and lead editor of Nivarana.
Siddhesh Zadey is a Researcher at the Department of Surgery at Duke University School of Medicine, a Co-founding Director of a non-profit think-and-do tank - Association for Socially Applicable Research (ASAR) based in India, and the Chair of the SOTA Care in South Asia Working Group of the G4 Alliance.
Image by Purvi Kedia.
This article was originally published in Nivarana.