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.

Nirbhaya… And Us!

It has been a year since we observed one of the most heinous crimes of the mankind… A brutal gang rape that culminated in the death of its victim, Nirbhaya. Everybody, right from the media to the most common citizen of India, has been discussing the incident for the last entire year in newsrooms, living rooms, classrooms, kitty parties, students' organization meetings, women's organizations, smoking areas of corporates, local trains, bus stops and at every place where two sensible persons meet. We have had debates, discussions, committees, schemes, and many other things as a result of the outrage of Nirbhaya case.

And yet… we have rape cases doubled and molestation cases risen by 6 times in the last year. One may say that rape cases have doubled, while some may opine that reporting of rape cases have doubled, which might be looked at as a positive sign. However, we are certain that if rape cases have indeed doubled, it is an alarming situation. Increase in reporting will mean that the subject has received much more recognition in comparison to a year ago. It will also mean that victims are not scared of being stigmatized as they were a year ago. It will also mean that maybe people have started vesting their faith in the system (police, law, judiciary all put together), thinking that they have a chance of getting justice. This may lead to more complaints being lodged. Same goes with molestation cases too. All these figures are always open for interpretation…

What is not open for interpretation is the fact that women, young and old, urban and rural, traditional and modern, professional women and housewives, are still being raped and/or molested in homes, offices, buses, dark alleys, hotel rooms, cars, beaches, toilets… everywhere!

What we must understand is that rapes are not only numbers, but real life traumas experienced by women which leave them scarred for the rest of their lives. Rapes are irreversible facts of every woman who has experienced that brutality. Rapes are a brutal reality threatening our everyday lives. Rapes are a mentality that is hampering our lives as individuals and as a society. It is hampering our interpersonal relations in a way that is making every day worse than the previous one.

We have already reached a state where every girl is taught, either directly or indirectly, to look upon any man or boy as a probable molester and to keep distance from every man or boy. It is not hard to imagine where this is going to lead us. And this is not going to change, even if incidence of rape cases goes down… And as long as one woman is being raped somewhere, the fear of being the next one will lurk in the minds of all other women. Because as we all know, none of us is safe till all of us are safe! 

Killing is killing… Honour or not!

On 20^th September 2013, there was this news of honour killing from Haryana, where the father, after stabbing his own daughter to death and beheading her lover in front of his own house said that ‘he had done no wrong’ and that ‘he had done it for the honour of the family’.

The sequence of events shows that it was not some impulsive reaction because his daughter eloped with a so called unsuitable boy. Such act can plead no excuse even being impulsive, but this was way worse. It was a planned cold blooded murder.The family of the girl followed the couple to Delhi, brought them back to the village and murdered them.

When we get past the initial shock and repulsion, the first question that comes to our mind is what must the father, or in this case the father, mother and the uncle have though? What emotions must have crossed their minds? They were talking about killing their own daughter.

A girl who took her first step before their eyes… Her parents must have been the ones to catch her before she fell!

A girl who spoke her first word of life to them… That might have been ‘Maa’ or ‘Bapu’ or ‘Chacha’!

A girl who went to school in front of them… They must have dropped and picked her up from school so many times!

She was a part of their everyday life. What must they have thought when they decided to kill her? Were they so angry that their anger overpowered their love? Or was there never enough love to pull through a situation like this? Was she always the secondary sex?

If they were so angry that they could murder their own daughter in cold blood, what might have prompted that level of fury? They said that the act of their daughter had insulted them in the society. What might have made them think that marrying someone of her choice was an insult to the family? What kind of social pressures must exist there? What reaction would the society have given, had they supported their daughter?

This act is heinous to say the least and the father, mother and uncle have already been arrested. The law will take it’s own course and we can hope that they will get the punishment they deserve. But are they the only criminals?

What about the society that convinced them that a daughter was better dead rather than married to an unsuitable boy? What about the social dynamics that have prompted a complete silence from the family of the boy? What about the social norms those deny personal space? And most importantly what about the mindset of the society at large that thinks that a man can have so much control over a woman that he thinks he is within his rights to kill her?

Click for the news that inspired the blog  Here

Murder or social evil?

The panel discussion at the launch of the Our Girls and Our Pride campaign had me thinking of clarifying a few points. We all know killing any one is a criminal act and should be treated as murder. Therefore, burning a daughter - in- law is a  murder. But is it the same as killing the son? How does the family, police and judiciary react to the two deaths? To begin with few deaths of daughters-in-law are reported as murders. They are reported as accidents or suicides. It is pre-meditated murder where often more than one family member is involved.  Why is it that the woman always dies in a fire accident in the kitchen or hangs herself? The death is planned to look like an accident or suicide. Why is she not shot or stabbed?

There is always an attempt to tamper evidence and influence the police to see that the case is not registered as murder. So who is going to treat it as murder? Similarly parents are also not willing to press for murder charges because of intimidation, fear that other daughters may not get married, economic constraints etc. The police also feel "hadsa hogaya hai" let's not make an issue of it to protect the honor of the family.  The criminal investigation is so poor that the case does not stand in the court.  The community remains a mute witness as it is seen as "ghar ka mamla" . I do not think the scene would be the same if a man kills his son whatever may be the provocation.

The question is why do we want to kill our daughter-in-law? We want to kill her because she has not brought in or bringing in more dowry which is seen as an entitlement of a man. Or because we got a better dowry deal from someone and want to bump off the girl to get a new bride.

A woman who seeks support from her family when  faced with violence and abuse from her husband and in-laws is often sent back by her parents saying her place is in her husband's house. Half- way homes, Legal aid  and other support mechanisms are almost non-existent. The laws which  are there to protect her, like all other laws  are ineffective, because of poor institutional mechanisms - budgets, human resources etc.

When we say dowry deaths are social evils we are addressing these issues which make us under play the gravity of the issue and the collusion of the social values, gender discrimination, institutionalized gender violence which make it so easy to kill our daughters-in-law.

By saying it is a social evil we are not undermining the criminality of the act. In fact we are saying that it is not being seen as a criminal act because of the social factors which need to be addressed. In spite of the Dowry act, DV act and 498 A , women continue to be killed with impunity and the system is not responding adequately because of the deep seated mindsets which trivialize the value of a woman's life.

Similarly, we all know that son preference has been an endemic problem in India. But with new technology, families have found a way to eliminate unwanted daughters. Sex-determination is a crime under the PCPNDT Act.  Yet so few convictions have taken place so far! Why? I agree that strict implementation of the law is the key. But who is going  to implement it? The doctors, the government, the judiciary? How sensitive are they to the issue?
What are the economic interests involved - of the family, the service providers, and the monitoring agencies? Can we address the problem of Pre-birth sex selection  without addressing the above issues.

I wonder why we think only of common citizens when we think of mind set change. Why do we think of advertisement campaigns, pamphlets and banners as the only means of mind set change? If we want to ensure that the 47000 ultra sound  clinics in the country are monitored strictly to stop pre-birth sex selection completely then we need to focus on those who are responsible for it. It has been proved that focused, intense interventions with specific stakeholders often results in desirable change. For instance in Maharashtra, the judicial colloquiums, sensitization programs for appropriate authorities and public prosecutors has ensured that close to 50 convictions have taken place under the PCPNDT act in the state.  This is just the tip of the  ice berg considering the scale of the issue. We have a long way to go as the latest census figures of Mumbai's sex ratio show. But I would say it is a good beginning.

Why this callousness di?

Twenty innocent lives were lost because of  our callousness. It is true that the school administration is primarily responsible for preparing and distributing the food. But it is not true that the school is wholly and solely responsible for it. Structurally a number of checks and balances are built in to the system. But they do not work because of the apathy of the people, their inability to fight for their rights and entitlements. I agree children are not the vote banks but parents are. When did you last hear of a village voting in the panchayat elections  making quality education, nutrition, health care, and employment as election issues? If the village community wants, it can pass a resolution to suspend the Sarpanch, it can audit the gram panchayat accounts and file RTIs to get information. There is so much power vested in the people. Then, why don't they exercise the power? Why the apathy? If an outside contractor comes and builds a sub-standard building we can understand the feeling of helplessness, but how do we explain when their own panchayat and community members build substandard buildings?

Working in 66 villages in Shahapur, we  see the functioning of the system very closely. Every village has at least 5-6 service providers - school teacher, Anganwadi Worker and Helper, pada worker for sanitation and surveillance, ANM and ASHA for  health services and gram sevak. Funds are disbursed and  utilized by the panchayat under the various schemes. Village level committees are constituted to ensure that the schemes are implemented efficiently and effectively by the service providers and the funds are utilized appropriately by the gram panchayat

However, it is frustrating to see that at every level the system is subverted. For instance, often the gram Panchayat members misappropriate the money with the connivance of the gram sevak, of course maintaining perfect records. Wells are cleaned, building are repaired, roads are laid and employment provided... all on paper. Accounts and records are maintained perfectly. The service providers are either hand in glove with the panchayat members are bulldozed and threatened to tow the line.

In most cases we found that the Village level committees for education and nutrition, water and sanitation etc are not functional. Many members are not aware that they are members, those who are members do not know what their roles and responsibilities are and finally those who are active are active for lining their pockets with little concern for the children,their own community members or their village. A few oonscientious  members are silenced by the powerful and are mute witnesses to the pilferage and misappropriation. In short, no body has a vision or dream for their village and lack pride in their village. There is total apathy, self serving leadership and large scale subversion of the system.

Let me narrate a case to highlight the issue. In one of the villages in Shahapur we found during public weighing of children that 24 of them were in the 3rd and 4th grade of malnutrition requiring immediate attention. However, in the records only 4 were shown as so. The AWW and ANM did not want to show so many cases in their records as it would reflect badly on them. Analyzing the situation we found:

Parents and other adults in the village were not aware of the significance of weight monitoring and did not pay attention to the children. Being a poor community, parents were daily wage laborers who had no time to seek medical help for their children.

The self help group which was providing food was only giving rice cooked with turmeric. No pulses, lentils,oil or vegetables were being given. The reason being, the group was to use their money and receive reimbursement later. Since reimbursements often did not come for more than 6 months they were reluctant to spend their money on procuring the appropriate rations.

The AWW and Helper were not actively working to convince parents to send the children to the Anganwadi

Parents were not keen on admitting the children in the hospitals as they could not afford to forego their daily wages on which the entire family survived
They were supposed to receive compensation for lost wages but the Primary Health Centres (PHCs) were not able to disburse the money on a daily basis for many reasons, which defeats the very purpose of having the provision.

The number of malnourished children was brought down to 4 within six months by plugging all the gaps. Adolescent girls were roped into counsel parents and accompany children to Anganwadi. SHG members were counseled about importance of nutrition and were convinced to provide food as per the nutrition chart, a camp was organized in the PHC with parents getting wage compensation on a daily basis.

The community understood the gravity of the problem and arranged through a donor to distribute one egg to each child as additional food supplement.

More importantly both ANM and AWW worker were motivated to take care of these children, of course with a warning that if they do not then the cases would be reported to their seniors.

Our delivery structures are good and our paper work is excellent. If we go only by the reports we would have nothing to worry about, but the reality is so different.

Do we shrug our shoulders and say that "we are like that only"! Would shifting the monitoring indicators from the quantity of services to quality of services improve service delivery? Who should measure the qualitative impact- third party researchers? Village community? So far the service providers are the providers, monitors as well as evaluators of the programme. Time we make the system work through people's participation.

Being Human

A few days back, after a session on gender sensitization a young colleague asked  me " if patriarchy is all pervasive and every institution supports it, is it ever possible to bring about gender equality?"

Recently there was a little tweeting on an advertisement of Delhi Police, where a daughter of a policeman says" I will follow the footsteps of my father" the question raised was why not show daughter of a police woman saying" I  will follow the footsteps of my mother"

Imagine how refreshing it would be if a son of a police woman was shown saying " I want to follow the footsteps of my mother" !

Patriarchy manifests differently and to varying extent in different contexts. What is important is for men and women to be conscious of it's existence and challenge it at every opportunity.

Look at our equations with our spouses. Are they equal? Are we making decisions consciously? Let me share with you a small study done by Sophia college students. Girls were asked to choose qualities and qualifications that they seek in their future husbands. Most girls chose better economic status, higher educational qualifications and assets over qualities such as understanding,sensitivity, liberal thinking etc. Thus marriage is aspirational for many women, get married into a wealthy family or to an IAS officer or what have you and your life is made. When marriage is based on such a requirement, how can we stop the practice of dowry and under valuing of women? Don't you think the equations would change when women start looking inward for fulfillment and achievement than gloating in reflected glory of the achievements of their husbands?

I cannot talk about gender equality to students if the equations between the male and female teachers is a reflection of the power equations at home. Male teachers being authoritative and female teachers being submissive. Female teachers engaged in cleaning and decoration work and men handling mikes and sound systems when there is an event. If a child never sees a man cooking or caring at home it would be very difficult for her/him to even imagine that it is possible. I have seen idiosyncrasies of male professors at the university level being ignored but those of the woman professors being exaggerated and stigmatized. And we ignore and often participate in it, because we are not using our critical thinking or wearing our gender lens.

Often people say that you are reading too much into an incident or a remark. If a sexist remark is passed do we just ignore it or show that  we have noted and not approved of it? I always feel we should be conscious of where to draw the line. It is your call and the other party has to respect it.

Gender is not about women. It is about the power equations between men and women. Just as we women fight for our right to be in the public places and work places, it is also important that we make space for men in kitchens and creches. I see women going into a frenzy when a male guest enters the kitchen to help, they do not mind my doing it, even if I am meeting them for the first time.

I also , particularly in middle and upper income families, that girls are being brought up to make them independent , confident and assertive. But at the same time there is no attempt to make the sons caring, nurturing and sensitive. They continue to be what they always have been   Dependent on women for all their daily needs,aggressive and violent.

When each one of us looks at oneself as a human being, and not as a man or a woman and are able to realize our full potential we would have a better society. Just imagine how beautiful life would be if only we could be rid of the burden of living up to the expectations of ourselves and others from us as a man or women.

Wake up India!

Once again there is justifiable anger at the molestation of a woman  by a pizza delivery boy. News anchors are hyper ventilating asking the question, Are women not safe at home anymore? They were never safe at home anyway as the domestic violence and rape statistics show.

There was also a discussion on it as a failure of our police and judiciary with a focus on whether we need to redefine the age of a "Juvenile"

There are also write ups in editorial pages saying that we need to address the issue of falling sex ratio if we want to address increasing crimes against women.

While I fully understand the need for better criminal investigation and quick justice and agree  about the possible escalation in violence against women due to shortage of women, to put the current incidents in that context is highly misplaced.

These are not frustrated middle aged men  who failed to get a wife. These are children, 15,16,17 years old who should be in high school dreaming of a bright future, may be having a girl friend, and some recreation.

Instead they are working in least remunerative and exploitative work conditions in jobs as delivery boys, courier boys, cable tv and other mechanics. They are paid less, are not respected for their work. They often face violence and humiliation at work. Most of them have run away from homes or live alone in slums. They see the rich and beautiful and are constantly exposed to the glitz and glamour. They have dreams of riding that beautiful bike with a girl they desire or love. All of which are not possible given their circumstances. The pent up anger and frustration leads to criminal activities or explodes into acts of violence particularly when the provocation comes from a woman who is in a much better position than they are, denting his macho image. These incidents are sexual crimes which are having strong socio-economic underpinnings.

A boy who delivers pizzas in US goes to school, goes back to a home which is comfortable and can afford to buy a pizza if he wants. The pizza boys in India see boys and girls of his age ordering pizzas which may be more than his salary for a month and represent everything that he wants but cannot afford. Imagine what goes in their mind?

The writing on the wall is very clear. We need more inclusive growth. We need more child friendly environment, where bad schools do not force children to run away from homes, where education builds the vocational skills of the students, where housing is decent, and food is adequate.

If the government and all other stakeholder groups do not take note of this as a symptom but as the disease, the incidents are only going to grow. Not just in number,may be in brutality as well.

Time to invest in our youth, otherwise our demographic dividend may turn out to be a demographic disaster.