Despite abortion being legal in India for almost five decades, every day 10 women die and thousands more face serious and permanent injuries due to unsafe abortions. This is unacceptable. Unsafe abortion is the third largest cause of maternal mortality and accounts for eight per cent of all maternal deaths in India. A recent study conducted jointly by International Institute for Population Sciences (IIPS), Population Council, New Delhi, and Guttmacher Institute, New York, estimates that only 22 per cent of the 1.5 crore abortions that occur in India every year take place at a private or public-sector facility and are performed by trained personnel.
The shortage of trained providers and concomitant lack of facilities offering safe abortion services are two of the key contributory causes of unsafe abortions. Unfortunately, the one policy action that could address this acute public health crisis is yet to be taken.
Abortion provision in India is governed by the Medical Termination of Pregnancy (MTP) Act, 1971. According to the Act, only allopathic doctors with specialisation in obstetrics and gynaecology or general practitioners who have undergone a 12-day certification training can legally provide abortion services. It is estimated that only 90,000 doctors in India meet this criterion. This is woefully inadequate to provide the (estimated) 1.5 crore abortions required every year. In addition, most of these providers are available in and around urban areas, leaving lakhs of women in rural areas without access to abotionists. Therefore, it is not surprising that 78 per cent abortions happen outside health facilities. This is both a public health and women’s rights issue that demands immediate redressal.
When the MTP Act was passed in 1971, the only available technology for conducting abortions was dilatation and curettage (D&C). This required anaesthesia and was an in-patient procedure that needed a provider to be highly skilled. Therefore, the lawmakers at the time restricted abortion provision to only those doctors who had the requisite skills and training. With the advent of newer and simpler technologies for abortion such as medication abortion, induced abortion is now a very safe and simple medical procedure. According to a study in the United States on abortion-related mortality between 1998 and 2010, meta-analysis of approximately 1.6 crore abortion procedures indicates that deaths associated with legal and induced abortion continue to be rare events — less than 1 per 1,00,000 procedures.
In 2015, the World Health Organization (WHO) released a guideline with evidence-based recommendations on the range of health-care providers who can effectively and safely perform abortions and provide post-abortion care. Recently, a broad-based stakeholder consultation was organised by the Ipas Development Foundation and Human Reproduction Programme, WHO, to compare the Indian scenario with the recommended global norms. Over 30 experts recommended that India make the necessary legal and policy changes to permit nurses and non-allopathic doctors to offer early abortion services, after suitable training. Given that there are more than 32 lakh nurses and non-allopathic doctors in the country, this will not only dramatically expand the provider base, but also decentralise abortion services to the lowest level of the public health system making them accessible, available and affordable.
This is not a novel, untried idea. Almost two decades ago, in the National Population Policy (2000), the Government of India declared the intent to strengthen and expand abortion services by including trained mid-level providers. Evidence from international and Indian research studies along with experience of more than 15 countries, such as Sweden, Bangladesh, Nepal and South Africa strongly indicate that early termination of pregnancy can be provided safely and effectively by trained mid-level providers.
Cognizant of these public health considerations and recognising the need for women to have more control over their reproductive rights, the Ministry of Health and Family Welfare drafted the amendments to the MTP Act in 2014, permitting nurses and AYUSH doctors to provide abortion services. The proposed amendments to the MTP Act have been on hold for the last four years.
In the meantime, India has implemented task-shifting and task-sharing for many maternal health, child health and family planning interventions, such as provision of life-saving anaesthesia, performance of C-sections by non-specialist physicians, and insertion and removal of intrauterine contraceptive devices by non-allopathic doctors and nurses. However, there is continued reluctance to allow these cadres to offer abortion services and bring abortion service provision in India in line with global standards.
Earlier this week was the International Day of Action for Women’s Health, and I hope the Government will take the action of amending the MTP Act. This will pave the way for making a trained abortion provider available at every facility close to where the poorest and disadvantaged women live.
I believe this single action will dramatically change the pathways for women who need abortion care and be the biggest advancement for women’s sexual and reproductive health and rights since the passage of the abortion law in 1971.
(The writer is executive director, Ipas Development Foundation)