Gaceta Médica de México Volumen Volume
139
Suplemento Supplement
1
Julio-Agosto July-August
2003
Artículo:
Legal but not always safe: Three decades of a liberal abortion policy in India
Derechos reservados, Copyright © 2003: Academia Nacional de Medicina de México, A.C.
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CONTEXTO SOCIAL medigraphic medigraphic
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Legal but Not Always Safe: Three Decades of a Liberal Abortion Policy in India
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Bela Ganatra, Batya medigraphic Elul
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Summary medigraphic
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La legislación sobre Terminación Médica del Embarazo de medigraphic medigraphic medigraphic medigraphic 1971, que permite el aborto en un rango amplio de escenarios médicos y sociales, liberalizó enmedigraphic forma importante medigraphic medigraphic medigraphic el acceso a la interrupción del embarazo en la India. A más medigraphic medigraphic medigraphic medigraphic de 30 años de su implementación, el aborto inseguro medigraphic medigraphic medigraphic medigraphic continúa siendo un problema importante. A pesar de la medigraphic medigraphic medigraphic medigraphic existencia de una política de aborto aparenteente liberal, medigraphic medigraphic medigraphic medigraphic las deficiencias importantes en su aplicación han llevado medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic amedigraphic una situación poco común en la cual lamedigraphic legalidad no se medigraphic medigraphic medigraphic medigraphic equiparar medigraphic con la seguridad. medigraphic medigraphic puede El medigraphic pobre acceso a proveedores de aborto certificados, las inconsistencias en medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic la calidad medigraphic de los servicios legales de conciencia medigraphic medigraphic y la falta medigraphic medigraphic medigraphic medigraphic medigraphic amedigraphic nivel comunitario sobremedigraphic la legislación y los factores medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic han contribuido medigraphic socio-culturales, a lamedigraphic predominancia medigraphic medigraphic medigraphic medigraphic continua demedigraphic aborto inseguromedigraphic en la India. Las investigaciones medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic y la militancia reciente, sin embargo, han sentado los medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic legislativa medigraphicque puede precedentes para una reforma medigraphic medigraphic medigraphic equiparar la legalidad conmedigraphic la seguridad.medigraphic La introducción medigraphic medigraphic medigraphic reciente de nuevos métodos de aborto, como la aspiración medigraphic medigraphic medigraphic medigraphic manual endouterina y el aborto médico tienen el potencial medigraphic medigraphic medigraphic medigraphic de incrementar el acceso a métodos seguros de medigraphic medigraphic medigraphic medigraphic aborto.
The Medical Termination of Pregnancy Act of 1971, which medigraphic medigraphic medigraphic medigraphic permits abortion on a wide range of medical and social grounds, greatly liberalized access to pregnancy termination medigraphic medigraphic medigraphic medigraphic in India. Over 30 years after its enactment, however, unsafe medigraphic medigraphic medigraphic medigraphic abortion remains a significant problem. Despite the existence medigraphic medigraphic medigraphic medigraphic of a seemingly liberal abortion policy, important deficiencies medigraphic medigraphic medigraphic medigraphic in its implementation have led to medigraphic an unusual situation in medigraphic medigraphic medigraphic which legality cannot be equated with safety. Poor access medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic to certifiedmedigraphic abortion providers, inadequacies in the quality medigraphic medigraphic medigraphic medigraphic medigraphic lack of awareness medigraphic medigraphic of legalmedigraphic services, of legislation at the community level,medigraphic and socio-cultural have all medigraphic medigraphic medigraphic medigraphic medigraphicfactors medigraphic medigraphic contributed to the continued predominance of unsafe abortion medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic in India. Recent and advocacy, however, are medigraphic medigraphic research medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic the medigraphic medigraphic paving way for legislative reform thatmedigraphic may put legality medigraphic medigraphic medigraphic medigraphic on a par medigraphic with safety. Themedigraphic recent introduction of new medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic abortion methods, such as manual vacuum aspiration and medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic are also likely medigraphic medigraphic medical abortion, to increase access to safe medigraphic medigraphic medigraphic medigraphic abortion. medigraphic medigraphic medigraphic medigraphic
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Palabras clave: Aborto, India, política, legislación medigraphic medigraphic medigraphic medigraphic medigraphic
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Key words: Abortion, India,medigraphic legislation, politics medigraphic medigraphic medigraphic medigraphic
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Introduction medigraphic medigraphic
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In 1971, themedigraphic Indian Parliament legalized abortion on a wide medigraphic medigraphic medigraphic range of medical and social grounds. With only three medigraphic medigraphic medigraphic medigraphic countries having more progressive abortion legislation in medigraphic medigraphic medigraphic medigraphic the early 1970s, the Medical Termination of Pregnancy medigraphic medigraphic medigraphic (MTP) Act medigraphic was hailed as landmark legislation. In addition to the medical indications permitted in many other countries, medigraphic medigraphic medigraphic medigraphic including physical danger to the mother’s health, rape, and
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fetal malformations, the MTP Act permits medigraphic abortion in cases medigraphic medigraphic medigraphic of potential injury to the mother’s mental health and among medigraphic medigraphic medigraphic medigraphic married women, contraceptive failure. In determining medigraphic medigraphic medigraphic medigraphic whether a pregnancy posesmedigraphic risks to the woman’s physical medigraphic medigraphic medigraphic or mental health, the MTP Act allows providers to consider medigraphic medigraphic medigraphic medigraphic the woman’s actual or reasonably foreseeable environment. medigraphic medigraphic Abortion ismedigraphic permitted up to medigraphic 20 weeks of gestation and no spousal consent is required, although parental consent is medigraphic medigraphic medigraphic medigraphic required for women under 18 years of age.1
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Correspondencia sobretiros: Bela Ganatra, Research medigraphic Manager, Ipas India, B-322 Clover Gardens, 4-Naylor medigraphic medigraphicy solicitud de medigraphic medigraphic medigraphic medigraphic medigraphic Road, Pune 411 001, India. Tel/Fax: 91-20-612 3065; E-mail:
[email protected] medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic Batya Elul, Program Associate, Population Council, One Dag Hammarskjold Plaza, New York, New York 10017, USA. Telephone: (212) 3390644; Fax: (212) 755-6052; E-mail:
[email protected] medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic
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medigraphic medigraphic medigraphic Thirty years after enactment of the MTP Act, however, medigraphic medigraphic the proportion of illegal abortions in Indiamedigraphic is believed to be medigraphic medigraphic two to ten medigraphic times that of themedigraphic legal component and unsafe medigraphic medigraphic medigraphic abortion is estimated to account for medigraphic 9 to 20% of all medigraphic medigraphic 2-7 medigraphic maternal deaths. Despitemedigraphic the existence of a seemingly liberal abortion policy, limited availability medigraphic of legal services, medigraphic medigraphic medigraphic significant barriers to quality services, pervasive confusion medigraphic medigraphic medigraphic regarding medigraphic abortion legalization at the community level, medigraphic medigraphic medigraphic medigraphic and socio-cultural factors have all hindered widespread use of safemedigraphic abortion services. In this paper, we describe medigraphic medigraphic medigraphic the process that led to legislative reform on abortion in medigraphic medigraphic medigraphic medigraphic India and describe the realities of abortionmedigraphic service delivery medigraphic medigraphic medigraphic there. Finally, we discuss how successes and failures in medigraphic medigraphic medigraphic medigraphic over 30 years of implementation of a liberal abortion policy medigraphic medigraphic medigraphic medigraphic in India can be applied to the development of abortion legislationmedigraphic in other countries. Much ofmedigraphic the information medigraphic medigraphic presented here has appeared elsewhere in more detail, medigraphic medigraphic medigraphic medigraphic and we refer interested readers to these publications.8 ,9 medigraphic
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Legislative Reform: Paving the Way formedigraphic Safe Abortion medigraphic medigraphic
medigraphic medigraphic medigraphic The move for liberalization ofmedigraphic abortion in India began as early medigraphic medigraphic medigraphic medigraphic as the mid-1960s, at the same time that many feminists in medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic Europe andmedigraphic the U.S. began advocating for access to abortion medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic countries.medigraphic medigraphicevery other in their respective In contrast to nearly medigraphic medigraphic medigraphic medigraphic country legislative reform ensued medigraphic in the 1960s and medigraphic where medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic 1970s, liberalized legislation in India medigraphic however, medigraphic demand for medigraphic medigraphic medigraphic medigraphic from the medigraphic medigraphic did not originate women’s movement. Rather, medigraphic medigraphic medigraphic medigraphic demographers and physicians paved the way for policy medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic discussions regarding abortion. While demographers argued medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic that accessmedigraphic to abortion wouldmedigraphic help curb the growing population medigraphic medigraphic medigraphic (something the existing Family Welfare medigraphic Programme had medigraphic medigraphic medigraphic program), been unable to do despite anmedigraphic active family planning medigraphic professionals medigraphic medigraphic medigraphic medical advocated for liberalized legislation in medigraphic medigraphic medigraphic an attemptmedigraphic to reduce morbidity and mortality from poorly 4 performed illegal abortions. medigraphic medigraphic medigraphic medigraphic In 1964 in response to pressure from these two groups, medigraphic medigraphic medigraphic medigraphic committee the Government of India appointed an 11-member to consider legalization of abortion. The committee, largely medigraphic medigraphic medigraphic medigraphic comprised of physicians or individuals closely allied with medigraphic medigraphic medigraphic medigraphic the medical community, reviewed published studies of medigraphic medigraphic medigraphic medigraphic complications of abortion and prevailing abortion legislation medigraphic medigraphic medigraphic medigraphic in a number of other countries, including Britain, India’s medigraphic medigraphic medigraphic medigraphic former colonizer. They also conducted an opinion survey medigraphic medigraphic medigraphic of national-medigraphic and state-level policy makers, influential medical providers, family planning officials, religious leaders, medigraphic medigraphic medigraphic medigraphic representatives of the legal community and the nascent medigraphic medigraphic medigraphic medigraphic women’s movement, although the vast majority of the 570 medigraphic medigraphic responsesmedigraphic received were medigraphic from the medical community. medigraphic medigraphic medigraphic medigraphic provided After 2 years of deliberation, the committee medigraphic medigraphic for liberalization medigraphic of abortion, medigraphic recommendations and 5 years medigraphic medigraphic medigraphic later in 1971 after further medigraphic input from the vocal medical 10 community access to abortion was liberalized. medigraphic medigraphic medigraphic medigraphic
medigraphic medigraphic medigraphic medigraphic Implementation: The Promise of Reproductive medigraphic medigraphic medigraphic medigraphic Freedom Cut Short medigraphic
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medigraphic As the Indian Penal Code of 1860 permitted abortion only medigraphic medigraphic medigraphic medigraphic to save the life of the woman and called for any person medigraphic performing an abortion a woman who induced medigraphic medigraphic medigraphic (includingmedigraphic her own abortion) for any other reason to be imprisoned medigraphic and/or medigraphic fined, the MTP Act of 1971,medigraphic which went medigraphic into effect medigraphic medigraphic medigraphic abortion on Aprilmedigraphic 1, 1972, significantly liberalized laws in India. medigraphic Ultimately, however, significant problems in medigraphic medigraphic medigraphic implementation ofmedigraphic the MTP Act have cut short its promise medigraphic medigraphic medigraphic of reproductive freedom. medigraphic medigraphic medigraphic medigraphic medigraphic
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Access to Services
In addition to liberalizing access tomedigraphic abortion, themedigraphic MTP Act medigraphic medigraphic also included a number of provisions regarding delivery of medigraphic medigraphic medigraphic medigraphic services that have proved to limit access to safe abortion: medigraphic medigraphic medigraphic medigraphic for example, abortions can only be performed by medigraphic medigraphic medigraphic medigraphic gynecologists or physicians who have had 6 months of medigraphic medigraphic medigraphic medigraphic training or have undergonemedigraphic abortion training medigraphic in gynecology medigraphic medigraphic medigraphic medigraphic medigraphic and certification atmedigraphic a government-approved training facility. medigraphic medigraphic medigraphic medigraphic Physicians trained in indigenous systems of medicine, medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic nurses,medigraphic and midwives are not permitted to provide abortions. medigraphic medigraphic medigraphic medigraphic medigraphic abortions medigraphic can only medigraphic Additionally, be providedmedigraphic at public medigraphic medigraphic medigraphic medigraphic sector medigraphic facilities or at private clinics that havemedigraphic received medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic certification frommedigraphic the government. Abortions performed medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic between 12medigraphic and 20 weeks’ gestation require approval from medigraphic medigraphic medigraphic medigraphic 1 two physicians. medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic Not surprisingly given these restrictions, access to medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic legal abortion services remains largely inadequate: while medigraphic medigraphic medigraphic10,000 medigraphic India currently has approximately certified abortion medigraphic with medigraphic medigraphic centers a population ofmedigraphic one billion, this translates into 11 medigraphic medigraphic medigraphic only 10 abortion centers permedigraphic million people. Additionally, medigraphic medigraphic medigraphic distribution across and within states ismedigraphic starkly uneven. For instance, the four large northern medigraphic states of Bihar, medigraphic medigraphic medigraphic Madhya Pradesh, Rajasthan, and Uttar Pradesh account medigraphic medigraphic medigraphic medigraphic for over 40% of the country’s population, but have only 16% of all approved abortion centers. In contrast, medigraphic medigraphic medigraphic medigraphic Maharashtra, a state on the western coast with less than medigraphic medigraphic medigraphic medigraphic 10% of the country’s population, has more than one fifth medigraphic medigraphic medigraphic medigraphic of the nation’s legal centers.3,4,12 Moreover, the vast medigraphic medigraphic medigraphic medigraphic majority of abortion facilities are located in urban areas, medigraphic medigraphic medigraphic medigraphic while over 70% of Indian women live in rural areas. medigraphic medigraphic medigraphic According to the MTP medigraphic Act, public-sector facilities at the primary-care level and higher are to provide abortion medigraphic medigraphic medigraphic medigraphic services. In reality, however, abortion services are medigraphic medigraphic medigraphic medigraphic generally available only at higher levels of the health-care medigraphic medigraphic medigraphic medigraphicconducted system. A four-state study of abortion facilities medigraphic medigraphic medigraphic medigraphic in 1996 found that only 24–58% of primary health centers medigraphic medigraphic medigraphic were providing abortion services, althoughmedigraphic all are mandated medigraphic medigraphic by law tomedigraphic do so.11 A recent nationalmedigraphic facility survey conducted by the Government painted an even bleaker medigraphic medigraphic medigraphic medigraphic
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medigraphic medigraphic medigraphic picture, finding only 5% of all primarymedigraphic health centers medigraphic medigraphic medigraphic offering MTP services. Nearly 90% ofmedigraphic the centers not medigraphic medigraphic medigraphic medigraphic offering services lacked providers trained in abortion.13 medigraphic medigraphic medigraphic medigraphic Given the public sector’s inability to meet the demand medigraphic medigraphic medigraphic medigraphic for abortion services, the private sector provides the bulk of legal services. in the statemedigraphic of Maharashtra medigraphic medigraphic For instance, medigraphic the private sector accounts for two thirds of all approved medigraphic medigraphic medigraphic medigraphic 14 abortion centers. At the same time, many trained medigraphic medigraphic medigraphic in facilities medigraphic gynecologists provide abortions that remain unregistered and therefore illegal, largely due to the medigraphic medigraphic medigraphic medigraphic bureaucratically process medigraphic medigraphic complex registration medigraphic medigraphic for private 8,15 ,16 providers.medigraphic In addition to a trained and certified medigraphic medigraphic medigraphic physician, private clinicsmedigraphic must havemedigraphic access to an medigraphic medigraphic anesthetist and on-site equipment for general anesthesia medigraphic medigraphic medigraphic medigraphic and abdominal surgery. As the clinic needs to be approved by state- and district-levelmedigraphic authorities,medigraphic the registration medigraphic medigraphic process requires several site inspections and may take medigraphic medigraphic medigraphic medigraphic several years. A recent survey of 118 members of the medigraphic medigraphic medigraphic medigraphic Federation of Obstetric and Gynecological Societies of medigraphic medigraphic medigraphic medigraphic India (FOGSI) who were providing abortion services found medigraphic medigraphic that 44% medigraphic of respondentsmedigraphic encountered difficulties in medigraphic medigraphic medigraphic medigraphic navigating the registrationmedigraphic process, including medigraphic medigraphic medigraphic 13% who medigraphic medigraphic medigraphic reported delays of 1–7 years in registeringmedigraphic their facilities.17 medigraphic medigraphic medigraphic medigraphic While studies have shown that when women have medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic access to medigraphic services, they prefer providers they perceive medigraphic medigraphic medigraphic medigraphic 18-20 medigraphic medigraphic as qualifiedmedigraphic or safe, given problems inmedigraphic accessing safe medigraphic medigraphic medigraphic medigraphic services inmedigraphic both the public and formal private sectors, the medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic informal sector, of a multitude of illegal and medigraphic medigraphic comprised medigraphic medigraphic medigraphic medigraphic medigraphic untrained providers–chemists, traditionalmedigraphic birth attendants, medigraphic medigraphic medigraphic medigraphic registeredmedigraphic medical practitioners, and physicians medigraphic medigraphic nurses, medigraphic medigraphic medigraphic medigraphic medigraphic qualified in other systems of medicine–remains a common medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic source of medigraphic abortion services in many medigraphic rural areas.21,22 medigraphic medigraphic medigraphic sector medigraphic Services provided by the informal range from the medigraphic medigraphic medigraphic medigraphic such as provision of non-invasive abortificients, medigraphic medigraphic medigraphic medigraphic ergometrine derivatives, antimalarials, oxytocics, and medigraphic medigraphic medigraphic aryuvedic preparations, medigraphic to performance of invasive procedures, such as vacuum aspiration and foreign body medigraphic medigraphic medigraphic medigraphic material insertion.18,21,22 medigraphic
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Quality of Care
A number of important barriers to the provision of quality medigraphic medigraphic medigraphic medigraphic abortion services exist in India. Physicians trained in medigraphic medigraphic medigraphic medigraphic abortion are often unavailable, inadequately trained, or not medigraphic medigraphic medigraphic 11,12 Gynecologists medigraphic confident in performing abortions. are reluctant to work in rural areas and with only 240 recognized medigraphic medigraphic medigraphic medigraphic abortion training centers nationwide, non-gynecologist medigraphic medigraphic medigraphic medigraphic physicians do not have adequate opportunities to be medigraphic medigraphic medigraphic certified. While there is littlemedigraphic information on the number of medigraphic medigraphic medigraphic medigraphic physicians trained per center, most centers function well medigraphic capacity medigraphic medigraphic to physicians medigraphic below and cater primarily from the medigraphic sector. medigraphic medigraphic medigraphiccurriculum public With no standardized training and smallmedigraphic caseloads, themedigraphic majority ofmedigraphic physicians are medigraphic
medigraphic medigraphic certified withoutmedigraphic having received sufficient medigraphic practical medigraphic medigraphic medigraphic experience to confidently and safely providemedigraphic abortion medigraphic medigraphic medigraphic services. Indeed,medigraphic one study in Maharashtra revealed that medigraphic trainees assistedmedigraphic in or performedmedigraphic an averagemedigraphic of 12–13 medigraphic medigraphic medigraphic medigraphic abortions, as opposed to the prescribed norm of 25.11 medigraphic Furthermore, training centers include vacuum medigraphic fewmedigraphic medigraphic manual medigraphic aspiration, medical abortion, or non-clinical aspects of medigraphic medigraphic qualitymedigraphic service delivery such as counselingmedigraphic in their medigraphic medigraphic medigraphic amplemedigraphic curriculum. Not surprisingly then, despite evidence in favormedigraphic of vacuum aspiration sharp curettage ismedigraphic still often medigraphic medigraphic 12,20,23 used tomedigraphic terminatemedigraphic pregnancies in medigraphic the first trimester. medigraphic Even when appropriately trained, often medigraphic medigraphic medigraphic providers medigraphic selectively refusemedigraphic to provide services. about medigraphic medigraphic Concerns medigraphic risks of providing services in facilities lacking adequate medigraphic medigraphic medigraphic medigraphic equipment, supplies, or medications to handle complications prompted government physicians medigraphic have medigraphic medigraphic medigraphic to be unnecessarily cautious when accepting clients and to medigraphic medigraphic medigraphic medigraphic reject potential clients on unsubstantiated health grounds medigraphic medigraphic medigraphic medigraphic such as advanced pregnancy and anemia.20 One study medigraphic medigraphic medigraphic showed that concern about potential litigation medigraphic under the medigraphic medigraphic medigraphic Consumer Protection Act was the reason for medigraphic refusal of medigraphic medigraphic medigraphic medigraphic services tomedigraphic all but the safest cases at a medigraphic secondary-level medigraphic medigraphic 20 medigraphic medigraphic medigraphic hospital. Some medigraphic providersmedigraphic also refuse services on moral medigraphic medigraphic medigraphic grounds, even in legally acceptable situations.11 Many medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic also widely approve of and require spousal consent, medigraphic medigraphic medigraphic 19 medigraphic medigraphic medigraphic medigraphic medigraphic by law. although not mandated medigraphic medigraphic medigraphic medigraphic Deficiencies inmedigraphic basic facility infrastructure further medigraphic medigraphic medigraphiclimit medigraphic medigraphic medigraphic medigraphic provision of quality services, particularly in the public medigraphic medigraphic medigraphic medigraphic medigraphic Functioning medigraphic medigraphic sector. centersmedigraphic often work under poor hygiene medigraphic medigraphic medigraphic medigraphic conditions. Manymedigraphic lack water or toilets and are medigraphic unable to medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic offer clients a clean procedure table or privacy. Shortages medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic of suction machines, cannulae, dilators,medigraphic analgesics, and medigraphic medigraphic medigraphic anti-hemorrhagic medications and an medigraphic irregular power 12 medigraphic all impede medigraphic medigraphic medigraphic supply consistent service provision. medigraphic medigraphic medigraphic Poor treatment of clients and lack ofmedigraphic counseling also medigraphic the medigraphic medigraphic affect quality of abortion services. medigraphic Indeed, it is not uncommon for women seeking pregnancy termination to medigraphic medigraphic medigraphic medigraphic experience judgmental, unsympathetic, or even abusive behavior, medigraphic particularly medigraphic in themedigraphic public sector, medigraphic where there is 20,24 little incentive to invest in good client communication. medigraphic medigraphic medigraphic medigraphic Counseling is not a routine part of abortion service medigraphic medigraphic medigraphic medigraphic delivery. While family planning services are linked to medigraphic medigraphic medigraphic medigraphic abortion services, great emphasis is placed on longmedigraphic medigraphic medigraphic medigraphic term, provider-dependent methods such as the medigraphic medigraphic medigraphic medigraphic intrauterine device (IUD) or sterilization, and the majority medigraphic medigraphic medigraphic of women are not providedmedigraphic with counseling on the range of possible contraceptive options. Coercive contraception medigraphic medigraphic medigraphic medigraphic is not unheard of.12,19,24 medigraphic medigraphic medigraphic While quality of care in the public medigraphic sector, poor or medigraphic medigraphic medigraphic medigraphic otherwise, can be monitored, little or no information exists medigraphic medigraphic medigraphic medigraphic concerning functioning of private abortion centers. medigraphic medigraphic Certification, once given, ismedigraphic permanent,medigraphic with no periodic medigraphic medigraphic medigraphic of care, medigraphic monitoring of quality for standards and compliance with reporting requirements is rare. medigraphic medigraphic medigraphic medigraphic
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medigraphic medigraphic medigraphic :rop odarobale FDP Awareness of legal rightsmedigraphic under the MTP Act remains medigraphic medigraphic medigraphic nearly as low as at the time of legalization,medigraphic further hindering medigraphic medigraphic VCOnly ed medigraphic AS, use of legal services. 16%cidemihparG of men medigraphic and women in a recent in Rajasthan,medigraphic a state in northwestern India, medigraphic survey medigraphic medigraphic and 15% of women in Madhya Pradesh, aarap state in central medigraphic medigraphic medigraphic India, knewmedigraphic that abortion is legal in India.22,25 Similar findings medigraphic acidémoiB medigraphic arutaretiL medigraphic :cihpargideM medigraphic have been reported in studies conducted elsewhere in the sustraídode-m.e.d.i.g.r.a.p.h.i.c country, including 25% of women who reported medigraphic medigraphic one in which medigraphic medigraphic recent statedmedigraphic that abortion was illegal.18 medigraphic terminations medigraphic medigraphic Confusion and misperceptions regardingmedigraphic the MTP Act are medigraphic medigraphic medigraphic pervasive even among men and womenmedigraphic who reportedly medigraphic medigraphic medigraphic know that abortion is legal, with many unaware of correct medigraphic medigraphic medigraphic medigraphic gestational limits and indications for abortion. While the law does not deny access to abortion marital status, medigraphic medigraphic medigraphicbased on medigraphic pre-marital intercourse remains culturally stigmatized; thus, medigraphic medigraphic medigraphic medigraphic many men and women erroneously equate abortion legality medigraphic medigraphic medigraphic medigraphic 18,22 with an individual’s marital status. Similarly, communitymedigraphic medigraphic medigraphic based studies have found that nearly all medigraphic male and female medigraphic medigraphic medigraphic medigraphic respondents incorrectly believe that spousal consent premedigraphic medigraphic medigraphic medigraphic 19,22 abortion ismedigraphic mandated by law. medigraphic medigraphic medigraphic medigraphic medigraphic
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A number of socio-cultural factors also limit the use of safe abortion services in India. Among the most important medigraphic medigraphic of female is the highmedigraphic prevalence of medigraphic selective abortion medigraphic medigraphic medigraphic medigraphic fetuses. While the Pre Natalmedigraphic Sex Determination medigraphic medigraphic medigraphic Tests Act medigraphic medigraphic medigraphic medigraphic of 1994 rendered sex detection tests illegal, the cultural medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic premium on producing malemedigraphic heirs coupled with increasing medigraphic family medigraphic small norms andmedigraphic widespreadmedigraphic availability of medigraphic medigraphic medigraphic medigraphic ultrasound has led to frequent use of such tests in the medigraphic medigraphic medigraphicpregnancy early second trimester and ifmedigraphic the fetus is female, medigraphic medigraphic medigraphic medigraphicage limits. termination near or beyond legal gestational Lateness of the procedure and its illegality further jeopardize medigraphic medigraphic medigraphic medigraphic women’s safety.26 medigraphic medigraphic medigraphic medigraphic Similarly, the need for confidentiality often outweighs safety considerations for never married adolescents, medigraphic medigraphic medigraphic medigraphic widows, and separated/divorced women and may drive medigraphic medigraphic medigraphic medigraphic them to unsafe informal providers even when safer medigraphic medigraphic medigraphic medigraphic services exist. Confidentiality considerations have also medigraphic medigraphic medigraphic medigraphic been found to delay abortion seeking until the pregnancy medigraphic medigraphic medigraphic medigraphic is more advanced, further adding to the risk of 27 medigraphic medigraphic medigraphic medigraphic complications. medigraphic
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medigraphic medigraphic medigraphic medigraphic in India is Not all is bleak as far as the abortion situation medigraphic medigraphic medigraphic to reduce medigraphic concerned, however. In an attempt bureaucratic medigraphic and medigraphic medigraphic medigraphicthe Indian delays hurdles in clinic registration, Parliament recently passed an amendment to the MTP medigraphic medigraphic medigraphic medigraphic
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Concluding Remarks
At the time of its enactment in 1971, India’s MTP Act was medigraphic medigraphic medigraphic medigraphic hailed as landmark legislation. The medical and population medigraphic medigraphic medigraphic medigraphic communities, which were intimately involved in lobbying for medigraphic medigraphic and in eventual medigraphicdraftingmedigraphic legislative change of the Act, hoped it would improve maternal health and curb population growth. medigraphic medigraphic medigraphic medigraphic Over the past 30 years, the Government of India has medigraphic medigraphic medigraphic attempted to ensure broad access to safe medigraphic abortion services medigraphicto the medigraphic medigraphic down primary-healthmedigraphic care level. Unfortunately, this medigraphic medigraphic medigraphic goal has been inadequately medigraphic met and mortality and morbidity medigraphic medigraphic medigraphic due to unsafe abortion remain significant.medigraphic Provisions built medigraphic medigraphic medigraphic into the MTP Act regarding who can medigraphic provide abortion services and where they can be provided, combined with medigraphic medigraphic medigraphic medigraphic
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medigraphic The Roadmedigraphic Ahead: Effortsmedigraphic to Remedy the Situation medigraphic
medigraphic medigraphic medigraphic Act thatmedigraphic decentralizes coordination of clinic registration to medigraphic medigraphic medigraphic medigraphic 28 the district level. Moreover, recognizing the need to medigraphic medigraphic medigraphic sustraídode-m.e.d.i.g.r.a.p.h.i.c increase accessmedigraphic to safe abortion, the Government’s medigraphic medigraphic medigraphic medigraphic National Population Policy (NPP) of 2000 recommended cihpargidemedodabor medigraphic medigraphic medigraphic medigraphic enhancing service provision efforts at primary health medigraphic centers. The NPP also suggested a shift away from medigraphic medigraphic medigraphic medigraphic electric vacuum aspiration to manual vacuum aspiration medigraphic medigraphic (MVA) medigraphic in rural areas where electricity suppliesmedigraphic are often medigraphic medigraphic erratic,medigraphic and endorsed introductionmedigraphic of medical abortion. Acting on the guidelines of themedigraphic NPP, the Government medigraphic medigraphic medigraphic in collaboration with FOGSI initiated a pilot program medigraphic to medigraphic medigraphic medigraphic integrate MVA into abortion services at primary health medigraphic medigraphic medigraphic medigraphic centersmedigraphic in eight states. in April 2002 medigraphic the Drugs medigraphicSimilarly, medigraphic Controller of India approved the antiprogestin mifepristone medigraphic medigraphic medigraphic medigraphic coupled with the prostaglandin misoprostol for pregnancy termination in gestations or less. Three Indian medigraphic medigraphic medigraphic of 7 weeks medigraphic pharmaceutical companies quickly began selling medigraphic medigraphic medigraphic medigraphic mifepristone and misoprostol, thus making medical medigraphic medigraphic abortion a viable medigraphic option for Indianmedigraphic women seeking early medigraphic medigraphic medigraphic pregnancy termination. Considerable in-countrymedigraphic research medigraphic medigraphic medigraphic on medical abortion conducted over the pastmedigraphic 10 years medigraphic medigraphic medigraphic medigraphic demonstrated that non-invasive abortionmedigraphic methods can be medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic and provided integrated into family planning services in medigraphic medigraphic medigraphic medigraphic rural areas.29,30 In March 2003, less than 1 year after medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic approval, the Government will medigraphic be hosting amedigraphic National medigraphic medigraphic medigraphic medigraphic medigraphicMeeting medigraphic Consensus on Medicalmedigraphic Abortion tomedigraphic discuss medigraphic medigraphic medigraphic medigraphic regulations for use in the public sector. medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic Recent yearsmedigraphic have also witnessed medigraphic of medigraphic medigraphic a resurgence medigraphic medigraphic medigraphicNumerous interest in medigraphic abortion research andmedigraphic advocacy. medigraphic medigraphic medigraphic research studies,medigraphic many collaborative efforts bymedigraphic a number medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic of non-governmentalHuntington D, Piet-Pelon NJ (Eds.) medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic organizations (NGOs), are medigraphic unearthing data on prevalence medigraphic medigraphic medigraphic services, of abortionmedigraphic in various states, quality of abortion medigraphic medigraphic medigraphic and women’s perspectives on access and medigraphic quality. Women’s medigraphicadvocates, medigraphic providers,medigraphic medigraphic health researchers, and policy makers medigraphicall been medigraphic medigraphic medigraphic have involved in lobbying for changes in clinic registration process and for adopting simplified certification medigraphic medigraphic medigraphic medigraphic requirements for first trimester pregnancy terminations.17
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medigraphic medigraphic medigraphic medigraphic significant problems in the quality of existing services, lack medigraphic medigraphic medigraphic of awareness regarding legal rights at the medigraphic community level, medigraphic medigraphic medigraphic medigraphic and socio-cultural factors have led to an unusual situation medigraphic medigraphic medigraphic medigraphic where legal services may not necessarily be safe and illegal medigraphic medigraphic medigraphic services, safe or unsafe, remain the mostmedigraphic accessible of all. What can other countries striving formedigraphic access to legal medigraphic medigraphic medigraphic abortion services learn from the Indian experience? Perhaps medigraphic medigraphic medigraphic most importantly, providers and policy medigraphic makers need to medigraphic medigraphic medigraphic form partnerships with other importantmedigraphic constituencies, including women’s health advocates, when lobbying for medigraphic medigraphic medigraphic medigraphic legislative change. Such consultation ismedigraphic likely to ensure medigraphic medigraphic medigraphic that policy,medigraphic when developed, is as usefulmedigraphic and realistic as medigraphic medigraphic possible. Given the lack of representation of the women’s medigraphic medigraphic medigraphic medigraphic movement in the development of the MTP Act, it is not medigraphic medigraphic medigraphic medigraphic surprising that the legislation is devoid of any mention of human and does not affirm women’s right to pregnancy medigraphic rights medigraphic medigraphic medigraphic termination per se. Additionally, information, education, medigraphic medigraphic medigraphic medigraphic and communication strategies must quickly follow legislative medigraphic medigraphic change to medigraphic ensure that women, men, andmedigraphic providers are all medigraphic medigraphic medigraphic medigraphic aware of legal provisions with regard to abortion Extensive medigraphic medigraphic medigraphic medigraphic efforts to effectively meet the demand for abortion services medigraphic medigraphic medigraphic are equallymedigraphic critical, so that women continue to turn medigraphic medigraphic medigraphic do not medigraphic medigraphic medigraphic medigraphic supports medigraphic to unsafe providers once legislation legal abortion medigraphic medigraphic medigraphic medigraphic services. At the same time, conducting in-country research medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic on medicalmedigraphic abortion for nearly a decade prior to approval of medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic has proved medigraphic critical in mifepristone and misoprostol medigraphic medigraphic medigraphic medigraphic developingmedigraphic a cadre of national experts ready to take the medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic method forward. should not be put on hold medigraphic medigraphic Such research medigraphic medigraphic medigraphic medigraphicis available. medigraphic medigraphic until the method medigraphic medigraphic medigraphic medigraphic While liberalization of abortion step in medigraphic medigraphic medigraphic is an important medigraphic medigraphic medigraphic medigraphic medigraphic providing access to safe abortion, over 30 years of medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic implementation of a liberal policy in India have demonstrated medigraphic medigraphic medigraphic medigraphicguarantee that legislative reform does not necessarily medigraphic medigraphicmakers, physicians, medigraphic medigraphic safety. Policy women’s health medigraphic medigraphic medigraphic medigraphic advocates, and other constituency groups must continue medigraphic medigraphic medigraphic medigraphic to work together to ensure that women’s reproductive rights are adequately met. medigraphic medigraphic medigraphic medigraphic
1. Government of India (GOI). The Medical Termination of medigraphic medigraphic medigraphic medigraphic Pregnancy Act (Act. No. 34);1971. medigraphic medigraphic medigraphic 2. Chhabra R. Abortion in medigraphic India: an overview. Demogr India 1996;25:83-92. medigraphic medigraphic medigraphic medigraphic New Delhi, 3. Chhabra R, Nuna C. Abortion in India: an overview. India: Ford Foundation;1994. medigraphic medigraphic medigraphic medigraphic 4. Jesani A, Iyer A. Women and abortion. Econ Polit Wkly medigraphic medigraphic medigraphic medigraphic 1993;28:2591-2594. medigraphic medigraphic of Medical Research medigraphic medigraphic 5. Indian Council (ICMR). Illegal abortion in rural areas: a task force study. New Delhi,medigraphic India: ICMR;1989. medigraphic medigraphic medigraphic 6. Karkalmedigraphic M. Abortion law andmedigraphic the abortion situation in India. Issues medigraphic medigraphic Reprod Genet Eng 1991;4:223-230.
medigraphic medigraphic medigraphic medigraphic Sood M, Juneja Y, Goyal U. Maternal mortality and morbidity medigraphic with medigraphic medigraphic associated clandestine abortions. J Indian medigraphic Med Assoc 1995;93:77-79. medigraphic medigraphic medigraphic medigraphic 8. Ganatra BR. Abortion India–what we medigraphic know, what medigraphic medigraphic research inmedigraphic wemedigraphic need to know. In: Jejeebhoy S, Ramasubban R, editors. medigraphic medigraphic medigraphic Women’s reproductive health in India. New Delhi, India: Rawat medigraphic Publications;2000. pp. 186-235. medigraphic medigraphic medigraphic medigraphic 9. Ganatra BR, Johnston HB. Reducing abortion related mortality medigraphic medigraphic in South Asia: amedigraphic review of constraints and a roadmapmedigraphic for change. J Am Med Womens Assoc 2002;57:159-164. medigraphic medigraphic medigraphic medigraphic 10. Government of India (GOI). Report of the committee to study medigraphic medigraphic medigraphic medigraphic the question of legalization of abortion. New Delhi, India: Ministry medigraphic medigraphic medigraphic medigraphic of Health and Family Planning;1966. 11. Khan ME, Barge S, Kumar N, Almroth in India: medigraphic medigraphic medigraphicS. Abortion medigraphic current situation and future challenges. In: Pachauri S, editor. medigraphic medigraphic medigraphic medigraphic Implementing a reproductive health agenda in India: the beginning. medigraphic medigraphic medigraphic pp. 507-529. medigraphic New Delhi, India: Population Council;1999. 12. Barge S, Khan ME, Rajagopal S, Kumar N, Kumber S. medigraphic andmedigraphic medigraphic medigraphic Availability quality of MTP services in Gujarat, Maharashtra, Tamil Nadu and Uttar Pradesh: an in-depth study. Paper medigraphic medigraphic medigraphic medigraphic presented at the International Workshop on Abortion Facilities medigraphic medigraphic medigraphic medigraphicNew and Post-Abortion Care in the Context of RCH Programme. medigraphic medigraphic medigraphic medigraphic Delhi, India;1998. 13. Government ofmedigraphic India (GOI). Facilities survey report.medigraphic New Delhi, medigraphic medigraphic India: Ministry of Health and Family Welfare;1998. medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic analysis medigraphic 14. Barge medigraphic S, Rajagopal S. Situation of MTP facilities in medigraphic medigraphic medigraphic medigraphic Maharashtra. Soc Changemedigraphic 1996;26:226-244. medigraphic medigraphic medigraphic 15. Iyengar K, Iyengar S. Elective abortion as a primary health medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic servicemedigraphic in rural India: experience with manual vacuum aspiration. medigraphic medigraphic medigraphic medigraphic Reprod Health Matters 2002;10:54-63. medigraphic medigraphic medigraphic medigraphic 16. Bandewar S, Lele M, Pisal H. Access tomedigraphic abortion services: medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic taking a stock of impediments. Paper presented medigraphic medigraphic medigraphic medigraphic at the State medigraphic medigraphic medigraphic medigraphic Level Consultation on Issues Related to Safe and Legal Abortion, medigraphic medigraphic medigraphic medigraphic Pune, India; 1998. medigraphic medigraphic medigraphic medigraphic 17. Sheriar NK. Navigating the MTP Act in clinical practice. J Obstet medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic medigraphic Gynaecol India 2001;51:25-29. medigraphicBR. Induced medigraphic abortions:medigraphic medigraphic 18. Ganatra programmatic and policy medigraphic medigraphic medigraphic medigraphic implications of data emerging from an ongoing study in rural medigraphic medigraphic Maharashtra, India. In: Purimedigraphic C, Van Look P,medigraphic editors. Sexual and medigraphic medigraphic medigraphic medigraphic reproductive health: recent advances, future directions. New medigraphic medigraphic medigraphic medigraphic Delhi, India: New Age International;2000. pp: 249-261. 19. Guptemedigraphic M, Bandewar S, Pisal H. Abortionmedigraphic needs of women in medigraphic medigraphic India: a case study of rural Maharashtra. Reprod Health Matters medigraphic medigraphic medigraphic medigraphic 1997;9:77-86. 20. Ramachandar L, Pelto B. The role of village health nurses medigraphic medigraphic (VHNs)medigraphic in mediating abortions in rural Tamilmedigraphic Nadu, India. Reprod Health Matters 2002;10:64-75. medigraphic medigraphic medigraphic medigraphic 21. Johnston HB, Ved R, Lyall N, Agarwal K. Postabortion medigraphic medigraphic medigraphic medigraphic complications and their management: a community assessment medigraphic medigraphic medigraphic medigraphic conducted in rural Uttar Pradesh, India. Chapel Hill, NC,USA: medigraphic medigraphic medigraphic Intrah, medigraphic PRIME II Project; 2001. 22. Elul B,medigraphic Barge S, Verma S,medigraphic Kumar N, Sadhwani medigraphic medigraphic H, Bracken H, Narvekar S, Uttekar V, Kshatriya P. Unintended pregnancy medigraphic medigraphic medigraphic medigraphic and abortion: a community-based study in Rajasthan– summary report. New Delhi, India: Population Council. (In press). medigraphic medigraphic 23. Singh medigraphic S, Wulf D, Jones H.medigraphic Health professionals: perceptions about induced Central andmedigraphic Southeast Asia. Int medigraphic medigraphicabortion in South medigraphic Fam Plann Perspec 1997;23:59-67. medigraphic medigraphic medigraphic medigraphic 24. Gupta J. People like you never agree to get it: an Indian family medigraphic medigraphic medigraphic medigraphic planning clinic. Reprod Health Matters 1993;1:39-43. medigraphic medigraphic medigraphic 25. Malhotra A, Parasuraman S, Nyblademedigraphic L, MacQuarrie K, Walia S, Kashyap N. Who medigraphic gets abortions and why: initial results medigraphic medigraphic medigraphic from a household-based survey in Madhya Pradesh. Paper
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Acknowledgments: We thank Hillary Bracken for very useful medigraphic medigraphic medigraphic medigraphic comments on a draft of this paper. medigraphic
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medigraphic medigraphic medigraphic presented at the Population Council Workshop – Abortion in medigraphic medigraphic medigraphic India: How Can Research Help Us Move Forward? Goa, India;2002. medigraphic medigraphic medigraphic medigraphic 26. Ganatra BR, Hirve SS, Rao VN. Sex selective medigraphic medigraphic medigraphic medigraphic abortions– evidence from a community based study in Western India. Asia medigraphic medigraphic medigraphic medigraphic Pac Popul J 2000;16:109-124. 27. Ganatra BR, Hirve SS. Induced abortionsmedigraphic among adolescent medigraphic medigraphic medigraphic women in rural Maharashtra, India. Reprod Health Matters medigraphic medigraphic medigraphic medigraphic 2002;10:76-85. medigraphic
medigraphic 28. Government ofmedigraphic India. The Medicalmedigraphic Termination ofmedigraphic Pregnancy medigraphic medigraphic medigraphic Actmedigraphic (amendment) bill. Bill No. XXXV; 2002. 29. Coyaji K. Earlymedigraphic medical abortion in medigraphic India: three studies and their medigraphic medigraphic implications for abortion services. J Am Med Womens Assoc medigraphic medigraphic medigraphic medigraphic 2000;55:191-194. medigraphic medigraphic medigraphic medigraphic 30. Coyaji K, Elul B, Krishna U, Otiv S, Ambardekar S, Bopardikar medigraphic A, medigraphic Raote V, Ellertson B. Mifepristone abortion medigraphic medigraphic C, Winnikoff medigraphic outside the urban research hospital setting in India. Lancet medigraphic medigraphic medigraphic medigraphic 2001;357:120-121.
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