Thursday, March 20, 2014

Avoidable and Unacceptable

Morbidity and Mortality resulting from Unsafe Abortions

The election fever had gripped the nation, with each of us trying to make sure that issues which matter to us are reflected in the political manifestos. It is the right time, to make the law makers and the political parties aspiring to determine the course of the country’s future in the next five years to give their commitment to these issues which are often neglected in public debate. Media is also doing its bit to draw the attention of the political parties and people to issues related, particularly, to women’s safety and wellbeing. This is one election where women are emerging as an important vote bank.

One issue which continues to remain neglected is the loss of maternal lives owing to lack of access to safe abortion services. Despite a liberal law governing abortion in India (Medical Termination of Pregnancy Act 1972), every two hours one woman dies in India due to complications arising out of unsafe abortion practices. Research documents that, every year 6.4 million abortions take place in India, of which nearly 56% are unsafe.
These startling figures reflect a number of issues related to abortion in India, the most significant being the non-availability of trained providers apart from ignorance about legality of abortions among people. Coupled with social stigma attached to abortion in the Indian social context, women with unintended pregnancies are often forced to turn to unsafe methods or to untrained providers to end their pregnancy, resulting in a high rate of avoidable maternal morbidity and mortality.

Yet another factor influencing abortion services is the misplaced attempt by the government to restrict abortions to control sex selective abortions, which are resulting in the fall of sex ratios across the nation. Data shows that, 80 to 90 percent of reported abortions in India take place in the first trimester when the sex of the baby cannot be determined. Sex selection can be done only in the second trimester of the pregnancy. Yet, every woman availing an abortion service is viewed with suspicion of indulging in pre-birth sex selection. The PCPNDT Act (Pre-Conception and Pre-Natal Diagnostic Techniques Act) focuses on sex determination alone. It is important to recognize pre-birth sex selection as a medical malpractice that is promoting the deep seated gender biases and son preference in the society. Whereas, safe abortion services are a legitimate entitlement of women with unwanted pregnancies resulting from contraceptive failure or rape and for women for whom the pregnancy is likely to result is physical or mental trauma or the survival or quality of life of the child is compromised due to congenital defects.

India is currently in the cusp of change where there is increase in young people engaging in sex at much earlier ages but at the same time the system dithering in providing them appropriate sex education and easy to access contraceptive services. Even today many health providers believe that there is no need to talk about condoms to girls. While the knowledge about contraceptive methods is almost universal, access to contraceptives is limited in many parts of the country.  It is estimated that even if all the eligible couples practice contraception, there would still be a need for abortion due to the 2-3% incident of contraceptive failure. It is in this context that one needs to focus on safe abortion services to the women.

The political parties need to be sensitive towards the issue of access to safe abortion within the ambit of women’s reproductive rights, this is particularly important in the context of the rising concern and pressure on the government to act to save the girl child. None of the political parties has ever specifically addressed the morbidity and mortality arising out of unsafe abortion practices in its manifesto, though maternal and child health issues are discussed. In the din of the rising concern for the safety of women in homes, on roads and workplaces, let’s not forget the safety of women when they are most vulnerable i.e during pregnancy and child birth. India still has the dubious distinction of a maternal mortality rate of 212 (SRS 2011) which is far above the natural incidence of 5 deaths per 1 lac live births. Eight percent of this mortality is due to unsafe abortions. It is time for the political parties to recognize and promote access to safe abortion services under the reproductive health rights of women.

India basically has a “physicians only” abortion law. The Medical Termination of Pregnancy (MTP) Act currently allows only gynecologists and MBBS doctors who have undergone specific training to provide abortion services. However, the latest developments in medical abortion, (where abortion is induced through drugs without having to undergo any intrusive surgical procedure) makes it safe even for the non-allopathic doctors and para medics to provide services, of course  when adequately trained to identify the complications arising out of it and refer the women to the appropriate institutions in case of complications. Data shows that a women has to travel on an average 20 Kms to access a abortion service provider and that there are only one service facility for 25000 women requiring the service. The number of providers could be significantly increased by amending the law to authorize medical practitioners with bachelor’s degrees in Unani, Ayurveda or Homeopathy to provide abortion care to provide medical abortion services.

Currently, as per the law, women must obtain the opinion of one doctor for a first-trimester abortion and the opinion of two doctors for a second-trimester abortion. This is especially difficult for women living in rural areas, where there are far fewer physicians. Simplifying and reducing the requirement for a provider’s opinion for both first and second trimester abortions would greatly increase women’s access.  Further, keeping the changing sexual behavior of young people in view, extending the condition of contraceptive failure for unmarried women as well would also help reduce number of women seeking unsafe abortions. 

Yet another issue which needs to be resolved is the need for abortion in later gestational period in certain exceptional conditions where substantial fetal abnormalities are observed much later into the pregnancy, there is a need to increase the upper gestational limit beyond the 20 weeks of gestation allowed as of now in the act. Technological and medical advancements in recent years have made late abortions safer than ever before.

Considering the widespread ignorance of the legality and availability of abortion services it is imperative that government simultaneously invests in creating awareness about the same. The challenge is to create that awareness without moralizing or stigmatizing abortion further.

At the implementation level there is an urgent need to implement the comprehensive abortion care training and service delivery guidelines to ensure that providers are trained and available at all levels of facilities and that they have access to required equipment and drugs to provide quality abortion services.

It is also absolutely important to establish district level committees for certification of private facilities for safe abortion services as mandated by the MTP Act.

Restricting access to safe abortion services for women has not only long term health consequences, but is also a violation of their reproductive as well as human rights. It’s time that it becomes as important an issue of women’s safety as other issues of violence against women.