The Medical Termination of Pregnancy (MTP) Act was passed in 1971. There were practically no discussions on abortion since then until the National Conference on ‘Making Early Abortion Safe and Accessible’ was held in Agra in 2000. This proved to be a milestone in the history of abortion discourse in India, as it marked the entry of abortion into the mainstream narrative on reproductive health.
The period 2000-05 witnessed the rise of new and safe technologies such as the Manual Vacuum Aspiration and the legalisation of medical abortion. The next five years saw the decentralisation of comprehensive abortion care (CAC) in the public health space and its introduction in the health objectives and training programmes. Since then, with the aim of addressing the persisting gaps in abortion, some notable measures were implemented by the government. These include the first-published CAC guidelines, mass media campaigns and a paradigm shift in the perception of MTP from a procedure-centric to a CAC-centric lens.
This momentum, however, failed to halt the spiraling gaps in the access to CAC services for women across the country. Access and awareness continue to be a glaring problem for women seeking abortion. To address them, the key focus areas that need urgent attention are expanding the provider base and redesigning the narrative on abortions.
A registered medical provider has the unique privilege of not just improving the health of patients, but also effecting behaviour change. So it is prudent for the provider base to be strengthened with knowledge and resources, which will help them leverage their influential position to bring about positive transformations.
The starting point should be expanding the provider base by increasing the number of service providers by permitting nurses, AYUSH doctors and auxiliary nurse midwives (ANMs) to undergo training and be included in the spectrum of legal abortion providers. Given that the majority of India’s population lives in rural areas, home to largely mid-level professionals, it is of utmost importance to train, equip and authorise them to provide abortion services.
The ANMs are already an integral component of the public health system—focusing on issues such as family planning, sexual and reproductive health and rights—at the grassroots, and are far more in number than doctors. Their potential remains untapped, as an increase in the number of ANMs providing abortion services could reduce maternal deaths. The WHO in 2000 proposed that one of the ways to increase abortion access is through trained mid-level providers.
Besides, a number of studies from India by the Population Council have shown that ANMs are as competent as doctors in providing abortion services. Exposing the candidates in medical colleges to rural areas, with a focus on quality CAC training will help in confidence-building. If the provider lacks confidence and is inclined to turn abortion-seekers away, the latter may end up resorting to illegal and unsafe methods. Often, many doctors as well as women are unaware that CAC can be provided at public health centres.
This is emblematic of a generic lack of awareness amongst the providers as well as abortion seekers, which can be solved by effective communication. One of the common problems is the legal conflation between abortion and gender-biased sex selection. There is an urgent need to destigmatise abortion in the medical fraternity as well as amongst the people, through the construction of a counternarrative that challenges the predominant ways of thinking.
It is a common misconception that the middle class, or those in urban areas have sufficient information on abortion-related matters. They too lack access to information and services, and efforts need to be bolstered to bridge this gap. There is also a greater need to liberalise mindsets, which tend to stigmatise rape survivors, unmarried women and other vulnerable women who may wish to undergo abortion.
Very often, these women have to face societal pressures and overcome legal barriers in their pursuit of abortion services— the right to which should belong to them. Considering there is increased access to technology in urban and semi-urban areas today, it can be used to demystify abortion and provide details about when, where and how to seek abortion services.
At the same time, access to new media has not reached villages yet, so it is important to customise the communication methods so that they have maximal efficacy. This can include the likes of wall paintings and IEC (Information, Education and Communication) materials using local language, instead of technical terms, for a simplified understanding of abortion and to demystify and destigmatise it.
Susmita Margaret, youth leader, Centre of Social Welfare and Rehabilitation, at a CAC Conclave held in New Delhi in July 2017 said that in the deep interiors of the country, the good old toll-free number would still be a great tool in “creating awareness and providing a platform for women to discuss their issues and seek information”. Susmita works closely with IDF, an NGO, on a project to increase awareness on sexual and reproductive health and rights issues among girls in select areas in Jharkhand, with a focus on encouraging health-seeking behaviour.
While we wait for the suggested amendments—that includes expansion of the provider base—to the MTP Act to be passed (after being abruptly put on hold by the PMO recently), we must simultaneously streamline efforts to communicate to providers and seekers alike, key abortion-related knowledge and the indispensability of making safe CAC services universally available to women.
Madhulika V Narasimhan
works for Footprint Global Communications. She writes extensively on public health, development, policy and governance issues