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No Contraceptives for 2.5 Crore Couples: Why India’s ‘Essential’ Abortion Service Isn’t Enough

By: Adrija Bose


Last Updated: May 02, 2020, 12:38 IST

Image for representation. Credits: AFP.

Image for representation. Credits: AFP.

The Coronavirus pandemic will leave 24.55 million couples in India without any access contraceptives, 900,000 unsafe abortions, and a steep increase in pregnancy-related deaths.

It took two weeks for a woman living in Bhiwandi in Maharashtra to get to an abortion clinic in South Mumbai after finding out she was pregnant. The journey usually takes about 2-3 hours.

After finding out she was pregnant, the woman got an appointment at the abortion clinic. But by the time she could arrange for a vehicle amid the lockdown, she had already crossed the seven-week limit to get a medical abortion and instead had to undergo a surgical one. "She was one of the lucky ones," a doctor who works at the hospital said.

India has declared abortion an 'essential' service, but medical experts and health professionals say one and a half million women will not be able to access safe abortion services during the lockdown.

"You would see a spike in childbirths next year," said VS Chandrashekhar, CEO at Foundation for Reproductive Health Services India (FRHS). Chandrashekhar, with a team of health experts, has conducted a study on the expected number of pregnancies that is likely to be the result of the lockdown, shifting focus to the containment of Coronavirus, lack of access to transport and unavailability of contraceptives.

The FRHS estimates that disruption to its services due to the Coronavirus could lead to nearly 2-3 million unintended pregnancies, 700,000 unsafe abortions and a steep increase in pregnancy-related deaths.

"In the best-case scenario, we expect  24.55 million couples being unable to access contraceptives due to the impact of the pandemic," said CEO of the largest provider of clinical Family Planning in the private/NGO sector in India.

Even as the World Health Organization has been urged to declare abortion as an essential service during the Coronavirus pandemic, women's access to abortion has become one of many healthcare provisions thrown into jeopardy. Abortion provider Marie Stopes International, which operates across 37 countries, predicts that up to 9.5 million vulnerable women and girls risk losing access to their contraception and safe abortion services due to the Covid-19 pandemic. "The consequences would be devastating," it said in a statement.

Future Gloom: What The Numbers Tell

In Ajmer, a couple on their way to an abortion clinic was stopped by the police. They were threatened to be arrested as they didn't have any 'evidence' for their essential doctor's visit. Only after an Asha worker intervened after spotting them in the middle of a scuffle that they were allowed to go. In Bareilly, a woman who lives 45 kms away from the FRHS clinic took three days to find transport in order to reach the clinic.

In their analysis, FRHS India, an affiliate of Marie Stopes International, found out that 24.55 million couples in the country won't be able to access their preferred modes of contraception during the pandemic. The NGO works towards improvement in accessibility and availability of quality family planning services in the states of Rajasthan, Bihar and Uttar Pradesh through public-private partnerships with the state governments.

"There's also a lack of family planning during this time," said VS Chandrashekhar, CEO, FRHS India. There are many reasons for that. While chemists are open, the footfall is low. Then there's the stigma part. When people buy over the counter contraception, they prefer to buy from a store that's away from their neighbourhoods. With the lockdown, that option is gone. "The organisations that sell and distribute these drugs to the chemist, they have not been able to function because of the lockdown leading to a shortfall of supply at stores," said Chandrashekhar.

The FRHS estimate pegs the number of unintended pregnancies at 1.5 million. "Half a million childbirths is predicted because of the lack of family planning and access to contraceptives. Another half a million are expected because of the lack of access to this 'essential' abortion services. An estimated 1.1 crore Oral Contraceptives, 8 lakh Emergency Contraceptives and 260 million condoms that would be sold normally won't be because of the lockdown.

The number of unsafe abortions is predicted to be at 900,000 and an additional 1,400 pregnancy-related deaths is also feared. "Maternal deaths is co-related to safe abortions. More unwanted pregnancy would lead to more unsafe abortions," said VS Chandrashekhar.

The estimates have been made by FRHS India based on services provided in the past years by the government and sales of over the counter contraceptives by social marketing organisations and private sector.

A large number of abortions are provided using medical methods and these drugs are usually available at chemists. While pharmacies are open, the health expert believes that it will be difficult for a lot of women to go to one. He said that some of them may be able to access abortion services after the lockdown but that would also imply that some of them would have exceeded the 20 day gestation period and moved to the second trimester. "With our current laws, many of them will be forced to continue their pregnancies," he said.

As the focus of the healthcare has shifted to the pandemic, the Ministry of Health and Family Welfare has issued an advisory to states recommending that intrauterine contraceptive device (IUCD), sterilisation and other chemical methods of birth control should not be provided during this time. Almost all states have stopped providing sterilisation services since 20th March. This would also imply more unwanted pregnancies. The data shows that 5,50,000 sterilisations and 7 lakh IUCD services that would normally be done during this period won't be available.

Sterilisation, in fact, has played an important role during crisis situations. Rather, reverse sterilisation. Dr Suchitra Dalvie, Coordinator for Asia Safe Abortion Partnership points out that in crisis situations and emergencies, people want to have more children. "It happened after the Tsunami," she said. Hundreds of women who were sterilised before as part of a government-sponsored family planning scheme aimed at cutting India's soaring population growth, reversed the operations. This was after the Tamil Nadu government announced to pay for surgery, bringing fresh hopes to those who had lost their children to the Tsunami.

"The impact of the lockdown and lack of access to birth control will not be visible immediately," Chandrashekhar said.

Across the world, the numbers paint a similar and bleak future. A recent report from the Guttmacher Institute shows that a 10% decline in contraceptive use would leave an additional 49 million women without access to modern contraceptives. And, the researchers say, if 10% of safe abortions become unsafe because women cannot access safe abortion services amid lockdowns and clinic closures, there would be an increase of 3 million unsafe abortions and 1,000 more maternal deaths.

Why It's So Hard To Get an Abortion

It's the messaging, believes Dr Suchitra Dalvie, Coordinator for Asia Safe Abortion Partnership. "Most women, especially from rural areas, think abortion is not legal," she said. The government's message against 'female foeticide' is lost in translation. In communicating the message of 'kanya bhrun hatya', the word is often dropped and left with 'bhrun hatya'. This, Dr Dalvie says, is confusing a lot of women who then believe that abortion is a crime.

Even without the lockdown, maintaining the secrecy and getting access to abortion services has been a big challenge for women across the country, said Dr Dalvie. The idea of a woman having control and rights over her own body is considered to be shameful, and it's not limited to India. "Women are told that the ultimate aim is to be a mother," she said, adding that this same idea has led to violence and deaths.

Since the outbreak of the pandemic, the Coordinator for Asia Safe Abortion Partnership has been receiving desperate calls for help from Jordan, Bhutan and Mumbai. "It was always difficult to access abortion services, with the lockdown, it's doubly challenging."

A day before the lockdown was imposed, a woman from Mumbai called Dr Dalvie to seek an abortion. She had just found out she is pregnant. "But she didn't have any transport to get to the clinic," said Dr Dalvie.

"We don't even know where they are going to get abortion services," said Sangeeta Rege of the Centre for Enquiry into Health and Allied Themes (CEHAT).

In many states, small clinics and nursing homes have not been functional during the lockdown. In Bihar, almost all the private facilities are shut down. Increasingly, OPD services have gone down and doctors are being reallocated to Covid-19 facilities. With limited access to the world outside, women are not even safe inside the confines of their own homes. An increase in domestic violence is evidence of that. "Women are unable to negotiate-- even about safe sex," said Rege.

Rege's organisation had to intervene to help a 19-year-old rape survivor get an abortion after she found out she is pregnant-- just as the nationwide lockdown began.

'Essential' But Not Available

"India, relatively a step ahead, declared abortion as an essential service. But essential doesn't translate into accessible," said Shwetangi, a medical student currently working as an intern in Cama Hospital, Mumbai.

Experts and medical professionals believe the listing of abortion services as 'essential' is not enough to protect women from violence and health risks.

Shwetangi has just been shifted from the gynaecology department and deployed in the Covid-19 ward of the hospital. "We are running routine OPDs but very few people are coming in," she said. "Many of them will not know who to reach out for help, and a lot of them won't be able to access it because of the unavailability of transport or means to get to a clinic," she explained.

Ayesha Bashir, Communications Officer at Asia Safe Abortion Partnership, said that the calls to helpline numbers have increased. "A woman who was late on her period cycle by a few days called the helpline asking what she can do if she is pregnant. There's also the added anxiety of not knowing how to get help," she said.

Telemedicine, Shwetangi said, is perhaps the solution. In the UK, women requiring an abortion during the UK lockdown can access a “pills by post” system, in which, the medication required will be sent to their mailboxes. The service is being offered by the British Pregnancy Advisory Service (Bpas) to women who are up to 10 weeks pregnant.

"But the practise of tele-medicine isn't enough in India and most women are not aware of the helplines," she said

The 22-year-old is a part of India Safe Abortion Youth (ISAY), an advocacy group of doctors and medical students, who sensitize the youth on issues surrounding sexual and reproductive health and rights. Their current fight is against the MTP Act which they say is "far from being pro-choice in the framework itself". There were new amendments proposed to the Parliament that, ISAY believes would widen the duration up to which a woman could seek an abortion with the intention of increasing the access to safe abortion. However, the Coronavirus pandemic disrupted the Parliament and any discussion on the MTP Act.

Now, ISAY has started a social media campaign on their proposed amendments to the Act. They are hopeful it will help people become more aware of their rights to reproductive healthcare facilities and the Parliament will pick it up in their Monsoon Session in July.

"There are multiple reasons why public sector hospitals don't even report as many abortions. One of them is that don't have enough equipment for it. One thing to look at would be how to increase safe abortions in the public sector," said VS Chandrashekhar.

The other issue with the Act, he said, is that in its current state very few doctors can legally provide abortion in India. "For long we have been advocating for expanding the base of the providers so that Ayush doctors, trained nurses can provide medical abortions. This is practised by a number of countries, in accordance with the WHO guidelines. Unfortunately, we have not been able to make that policy change," he said.

Perhaps a pandemic will be able to make the government amend the MTP Act and change its policies on abortion.