Abortion bill 2020 is good, but not good enough
The Medical Termination of Pregnancy (MTP) Amendment Bill, 2020, has got several things right. Raising the upper limit of legal abortions from 20 weeks to 24 weeks for “special categories of women”, including rape and incest survivors, other vulnerable women, and children; and completely removing the upper gestation limit for abortion in the cases of substantial foetal abnormalities will help many more seek safe and legal abortion services.
Other positive inclusions are allowing all women, and not just married ones, to legally seek abortions, and striking out the need for the opinion of a second registered practitioner for aborting pregnancies up to 20 weeks. The draft proposes that the opinion of two practitioners will now be needed only for abortions in the 20-24 weeks period.
The bill, however, falls short when benchmarked against the changes proposed in the draft MTP Amendment Bill 2014, with the biggest lacunae being the failure to expand provider base to offer safe abortion services to every women who needs them.
One in three of 48.1 million pregnancies in India end in an abortion, with 15.6 million abortions taking place in 2015, according to the country’s first large-scale study on abortions and unintended pregnancies, study published in The Lancet in November 2017.
Of these, around 12.7 million (81%) were medical abortions, and 2.2 million were surgical terminations of pregnancy done by certified doctors in registered facilities. The World Health Organisation (WHO)-recommended combinations of the oral pills, mifepristone and misoprostol, are the most common methods of medical abortion.
Need more providers
With an estimated 90% of women seeking before 12 weeks gestation, training village-level healthworkers (auxiliary nurse midwives) and nurses to prescribe simple abortion pills will help take safe services to the doorsteps of vulnerable women and, in case of complications, lead to timely referrals.
“Only 22% of 15.6 million abortions happen in healthcare facilities, there is no record of the others. We need far more providers at the lower levels of healthcare delivery to ensure safe abortion services reach more women,” said Vinoj Manning, chief executive officer of the Ipas Development Foundation in India, which works to provide safe abortion and other health services.
“Training mid-level providers for medical abortions, as recommended by WHO, is a practice in many countries, including developed nations such as Sweden and South Africa, and in neighbouring countries like Nepal, Bangladesh and Cambodia. It is a huge missed opportunity for India,” said Manning.
This gap in services can be addressed in the new rules that will be framed when the amended act is passed. “The training requirements specified in the MTP rules could be modified to include a two to three days short training on medical abortion for MBBS doctors (traditional training is for 12 weeks) to make them eligible to provide abortion using abortion drugs. This would dramatically expand the provider base as India has around 610,000 MBBS doctors, of which only 90,000 are currently trained to provide abortion services,” said Manning.
Too many players
Some others are suggesting the proposed law remove the upper gestational limit for rape and incest survivors. “Our analysis of court cases relating to abortion between 2017 and April 2019 shows that 41% of rape survivors who sought Court intervention had crossed 24 weeks of gestation. What could do more harm to the mental and physical health of a rape or incest survivor than carrying their rapist’s a pregnancy to term? It makes no sense,” said V.S Chandrashekar, chief executive officer, Pratigya Campaign for Gender Equality and Safe Abortion.
Doing away of medical boards that decide cases related to substantial foetal abnormalities would be another pro-women move. “In the past, we have seen girls and women face delays, stigma, and repeated invasive exams by different doctors. It’s another layer that is not just a barrier to seeking abortion care but also disrespectful towards women’s dignity and rights. It legitimises third party authorisation when abortion is a decision best left to a woman and her service provider,” said Chandrashekhar.
Complicating matters further is low awareness of abortion being legal in India. “Our study of 1,007 women of ages 15-24 years in Assam and Madhya Pradesh in November 2018 found only 20% young women know about modern contraceptive methods, and 22% are aware that abortion is legal in India. None of the women surveyed were aware of the correct legal gestation of 20 weeks,” said Manning. The survey, which included attitude to abortion, found 62% women believe abortion is a sin, and 33% said they would disown friends who have had an abortion.
Instead of denying services to women because of the apprehension of untrained practitioners profiteering, the government should focus on regulating the healthcare sector to ensure basic quality services, such as contraception, safe delivery and abortion, are available for the asking.
“Abortion should be made a right and available on request for at least for up to 12 weeks gestation,” said Chandrashekhar.