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Safe abortions: Why India needs more trained providers

Botched procedures kill 10 women every day; abortion deaths currently account for 8% of India’s 44,000 annual maternal fatalities.

columns Updated: Nov 25, 2017 19:34 IST
Sanchita Sharma
India needs to ensure that the laws that protect the right to choose, protect it for all women.
India needs to ensure that the laws that protect the right to choose, protect it for all women.(Getty Images / iStock)

One in four pregnancies worldwide ends in an abortion, which can be a very risky procedure if botched by an untrained provider. Yet, close to half of all abortions done worldwide are unsafe, killing 47,000 women and disabling another 5 million every year.

Of the 55.7 million abortions that occurred worldwide each year between 2010 and 2014, the most recent period for which data are available, only 30.6 million (54.9%) were safe, found a review of data from 182 countries. Of the 25.1 million unsafe abortions, 17.1 million were less safe and 8 million very unsafe, found a study published in The Lancet in September.

Legalising abortion makes it safe. In the 57 countries where abortion is available on request, 87.4% of abortions were safe, compared with 25.2% in the 62 countries surveyed where abortion was banned or allowed in legally restrictive settings. In developing countries, close to half (49.5%) were unsafe, compared to 12.5% in developed countries, the study found.

India’s Medical Termination of Pregnancy (MTP) Act legalised abortions up to 20 weeks in 1971, but close to half the women who abort use unsafe methods or go to quacks because they don’t know whom to approach. Many don’t even know it’s legal to abort a foetus up to 20 weeks.

In India, 6.4 million induced abortions are done each year, of which more than half (3.6 million) are unsafe and kill 10 women every day. Abortion deaths account for 8% of India’s 44,000 annual maternal deaths. All these deaths are preventable.

Winds of change

With newer medical techniques making abortions safe in late stages of pregnancy, the Union health ministry has proposed women-centric amendments to the MTP Act, 1971, to make abortions available on request up to 12 weeks; raise the upper limit of legal abortions from 20 to 24 weeks, with no upper limit for cases of foetal abnormalities; reduce the requirement from two service providers’ opinions for second-trimester pregnancies to one; and remove restrictive terminology to make the law consistent for all women, including changing ‘married’ to ‘woman’ to include single women in the clause relating to contraceptive failure, and changing the term ‘husband’ to ‘partner’.

The ministry, however, is considering rejecting the proposal to expand the base of legal medical abortion providers to include traditional practitioners of AYUSH (Ayurveda, Unani, Siddha and Homeopathy), nurses and village-level health workers trained to use non-surgical medical methods to terminate early-stage pregnancy. The decision stems from an apprehension that this could lead to more illegal sex-selective abortions, which have already led India’s child sex ratio -- the number of girls per 1,000 boys at age six – to fall from 983 in 1951 to 919 in 2011.

The arrest of a homeopathy practitioner for illegally performing sex-selective abortions in the Sangli district of Maharashtra in March this year led the Prime Minister’s Office to ask the health ministry to make the draft Medical Termination of Pregnancy (Amendment) Bill, 2014 more stringent to prevent misuse.

India banned sex determination and sex-selective abortions under the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act in 1994. While both acts – the MTP and PCPNDT -- regulate abortion, there is no overlap. PCPNDT is a regulatory Act that prevents misuse, while the MTP Act focuses on women’s rights and safety.

Need for more

Not widening of the provider base to include village health workers is regressive. Millions of women in India still don’t know that abortion up to 20 weeks is legal, with awareness being a low 36% in Bihar, according to a study conducted in 2012-13. Bringing in mid-level providers would ensure approved medical methods were used to abort early-stage pregnancies and women with more advanced pregnancies were referred to approved centres.

About 80% to 90% of induced abortions are currently done within 12 to 13 weeks of pregnancy, when the gender of the foetus cannot be determined, according to UNFPA and the Ipas Development Foundation. With improved regulation, increased misuse would be highly unlikely if trained village health workers were allowed to administer medication to terminate pregnancies up to seven weeks, and nurses and alternative practitioners, up to nine weeks. Surgical abortions could continue to be done only by registered physicians, who risk fines and imprisonment for sex-selective procedures.

The Protection of Children from Sexual Offences (POCSO) Act, meanwhile, treats all pregnant minors as rape survivors and mandates that all such pregnancies be reported to the police — which is leading some doctors turn away minors altogether, putting their lives at risk.

India needs to delink illegal sex- selection from abortions. And ensure that the laws that protect the right to choose, protect it for all women.