Abortion is legal in India, but it’s only when a woman goes to the clinic that she discovers the hurdles and the stigmatising that is so common among doctors and others in authority.
A newly-constructed three–storied building stood behind the mesh of electric wires hanging from a half-bent pole in Nangloi. The exterior was tinted silver glass fitted into copper panels. A yellow board declared the name of the doctor, boasting several international degrees and medals in gynaecology.
The receptionist asked her to sit in the waiting room. “There were three other women there, all in their twenties,” she recalls. She saw the doctor after half an hour. “He saw my mangalsutra and asked me ‘Are you really married?’, to which I had to confidently reply in the affirmative. I made up a story about how my husband is travelling and that’s why he couldn’t accompany me.”
An ultrasound and a pelvic examination later, the doctor confirmed that she had an incomplete abortion because of pills she had taken before, and that infection had set in. He recommended surgical evacuation. “He said the only option to get rid of it was through some vacuum aspiration method which would cost Rs. 10,000.” Thousands of Indian women die in India due to unsafe abortions.
She got Rs. 3,500 per month as pocket money, which included travel to college. Her friend Gayatri lent her Rs. 2,000, and another friend from college contributed Rs. 2,000. “I was still short by Rs. 2,500. I lied to my father. I told him my friend urgently needed money to pay the security (deposit) at her paying guest accommodation.” Her name is Mitra. She was 20 years old, in her second year of college. Two weeks earlier, she had found out that she was pregnant.
Mitra’s boyfriend had stopped taking her calls after she told him the pregnancy test was positive. Mitra had heard of acquaintances and friends undergoing abortions and had researched abortion pills online. Armed with that knowledge, Mitra went to a pharmacy and bought Cytotec, an abortion-inducing drug sold for Rs. 32. Misoprostol—the generic name of Cytotec—cannot be legally sold without a doctor’s prescription, but it can be easily bought over the counter, as was done by Mitra.
She dutifully followed the instructions to keep the tablets under her tongue for 30 minutes. Mitra started bleeding within two hours. Over the next two days, she missed college due to heavy bleeding and nausea, and later experienced morning sickness. She thought that it was an after-effect. She couldn’t sleep on her right side as it hurt. A week had now passed. Her friend spoke to some girls in her PG accommodation and suggested the clinic in Nangloi. “I was let off after half an hour in the operation theatre. For the next two hours, I was hallucinating,” she says.
A month later, she got a call from a courier company to confirm her address. Within an hour, a police officer with two women constables landed up at her house in Noida. The Nangloi doctor had been arrested a week earlier under the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act for conducting sex-selective abortions. Mitra’s number was found on the doctor’s phone.
Mitra was not allowed to go back to college. Her father didn’t speak to her for a month, till she started experiencing heavy abdominal pain and excessive vaginal bleeding. A proper diagnosis revealed an infection in her fallopian tubes: damage caused by the irresponsible surgical procedure performed by the Nangloi doctor. Mitra will never be able to conceive. She was forced to switch to the school of correspondence courses in Delhi University. She and her younger sister are hardly let out alone.
In India, a woman dies every two hours because she’s had an unsafe abortion, according to estimates by Ipas, an international organisation that works with the National Rural Health Mission to reduce maternal deaths due to unsafe abortions. In August, health minister Ghulam Nabi Azad said data on the number of unsafe abortions in India was unavailable in the Central Health Management and Information System of the National Rural Health Mission.
According to government data for 2008-09, however, a total of 11.06 million abortions were recorded that year. Abortion was made legal in India by the Medical Termination of Pregnancy (MTP) Act, which was passed by Parliament in 1971 and came into effect in 1972.
The Act permits abortion if the doctor believes “in good faith” that “…the continuance of the pregnancy would involve a risk to the life of the pregnant woman or of grave injury to her physical or mental health; or there is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped”. As a result of this focus on maternal health, the onus still lies on the woman to explain or prove how it will harm her physically or mentally. It is almost implied that married women must state contraceptive failure and single women must state coercion or rape as a reason for pregnancy.
Merely stating that it is an unwanted pregnancy is not enough. Then, in 2004, the government endorsed guidelines on the appropriate use of Mifepristone and Misoprostol for self-induced abortion. However, the government has not yet introduced drugs for abortion in public clinics and hospitals. On the face of it, abortion is legal in India—unlike in a number of Western countries—but women have hardly any control over their reproductive future.
What happened with Mitra is an example of how much female sexuality is controlled, moralised, and stigmatised. The MTP Act fails to define terms like “abortion”, “miscarriage”, “termination of pregnancy”, “health”, “substantial risk”, and “seriously handicapped”, making the doctor’s opinion sacrosanct.
According to a study by Ipas, 76 per cent of the women who come for first-time abortions are unmarried. Statistics collected by Mumbai’s International Institute for Population Sciences (IIPS), a public health organisation, show that about 21 per cent of males and four per cent of females in rural areas admitted to pre-marital sex against an urban figure of 11 per cent of males and two per cent of females.
The IIPS survey sample of 55,000 males and females comes from about 1.7 lakh households in Bihar, Jharkhand, Maharashtra, Rajasthan, Tamil Nadu, and Andhra Pradesh. The age range is 15-29. … Nineteen-year-old Jyoti is still struggling to cope with what has happened to her. The tiny, cheerful Jyoti, who studied till class six, belongs to the Ho tribe of Jharkhand and is from Gua village of West Singhbhum district.
Covered in Saranda forest, with the largest sal cover, the district has rich iron ore deposits and is dominated by Maoists. “A boy in my neighbourhood moved to Delhi to work. He used to get me gifts each time he visited the village. He told me that he loves me and wants to settle with me in Delhi,” recalls Jyoti. When Jyoti missed her period for the first month, she ate unripe papaya with peppercorn. She waited for two weeks with no result. “I ate dry henna powder later but it didn’t help.
That’s when I told my elder sister who is already married and lives in another village. She fumed and threatened to tell my parents. I pleaded and that’s when she took me to a dai (midwife) who did not know anyone from my family or village.” The dai diagnosed a pregnancy and asked Jyoti to keep an extract of medicinal roots and shrubs in her vagina for two to three days. It did not lead to any result.
After two months, the dai then gave her a concoction of boiled betel nut roots and jaggery. “It was bitter and caused immense pain in my abdomen. I could not go to the primary health centre and obviously could not tell my parents. I know they would have killed me.” It was then that Jyoti decided to call her boyfriend Tarun, 21, who was now an office boy in Delhi. “He was shocked but supportive. He came back to the village within four days and met my father, offering to marry me.
By the time Jyoti managed to reach Delhi, she had entered the second trimester of her pregnancy. A thorough check-up revealed that a 14-week foetus without a heartbeat was present in her womb. The foetus was surgically removed and Jyoti’s womb was perforated in the process. She can never be pregnant again.
While abortion through pills is considered safe, it often leads to haemorrhage, incomplete abortion, and is discouraged for anaemic women since it causes heavy bleeding. Surgery is a vacuum evacuation process that minimises the chances of incomplete abortion but is costlier, though quicker. Studies show that a considerable proportion—one-fifth—of young abortion-seekers delayed the termination of pregnancy until the second trimester.
The unmarried ones were significantly more likely to have done so than the married: one-quarter of the unmarried, compared to nine per cent of the married, delayed abortion until beyond 12 weeks of pregnancy. Last year, Savita Halappanavar in Ireland was denied a second trimester abortion because of Irish law and later died.
Though India joined the bandwagon in demanding changes in Ireland’s abortion law, second trimester abortions in India are difficult, life-threatening, and require approval from two doctors. They are also costly and far harder to obtain.
Single women are vulnerable; they are often unequipped to detect pregnancy, lack partner support, and have confidentiality issues that delay the process of seeking medical help. Dr Manisha Gupte, a pioneer in advocating abortion rights for women, says, “It is evident that women’s right to control their sexuality, fertility and reproduction were not the basis on which the MTP Act was formulated or interpreted. As a result, no government ever initiated programmes to make single women aware that they have a legal right to abortion.”
The government of India introduced family planning in 1952, and passed the MTP Act in 1972. It’s been 60 years since family planning was introduced, and 40 years since abortions were made accessible for women on many conditions, except on demand. MTP centres were opened in several government hospitals or independently to make abortion accessible to women who met the criteria. Yet these centres are often inaccessible and dismissed as an option.
The MTP centres originated with the understanding that they would contribute to family planning. Many operate under the assumption that the women who come to these centres are married. Often, abortion services are provided in exchange for promises to use contraceptives; in several cases, contraceptives like Copper T are inserted into the women’s vaginas immediately after abortion.
Moreover, most MTP centres are in urban areas, unavailable to rural women whose minds are in any case clouded with myths about abortion. The stigma around abortion also makes things doubly difficult for Indian women. In the Seventh Five-Year Plan (1985-1990), the government stated its intention of equipping all primary health centres to conduct abortions. Yet the dearth of such centres continues.
Fresh figures state that Uttar Pradesh and Bihar have the lowest ratios of MTP per 1,000 persons, even when they have the highest number of abortions. Not surprisingly, Bihar has one MTP centre for every 4,45,000 people. To avoid the hassle of travelling miles to government MTP centres, and to keep it quiet and avoid forced contraceptives, people prefer private clinics to government facilities.
According to ICMR, only 55 per cent of MTP centres provide manual vacuum evacuation, another alternative for termination of early pregnancy. This is a major deterrent. According to Heidi Bart Johnson, in her paper Abortion Practice in India, “Bureaucracy associated with registering MTP facilities with the government and with reporting and recording MTP procedures contributes to the end result that many physicians provide abortion illegally.”
The lack of institutionalised abortion rights turns women in vulnerable situations to private clinics. They charge exorbitant fees for low quality services. However, women are forced to barter quality for confidentiality which the bureaucratic MTP centres with their guilt-ridden and judgmental environments fail to provide. Also, Mitra and Jyoti’s cases may give the impression that the problem is limited to women who are economically dependent.
This is not the case. Prerna, 28, is a producer with an English entertainment channel in Delhi. “Because I live with my parents, I had to find the farthest possible clinic to get an abortion.” Prerna was working on a documentary on yoga at that point and was in a relationship with Satvik, who is the same age as her and also a media professional. “When I told him about the pregnancy, he freaked out. He told me that he wants to rethink the relationship since he didn’t expect it to reach ‘that’ level.”
Nevertheless, Satvik took Prerna to a clinic. The doctor, a woman in her mid-50s, asked, “Are you married?” “No”, Prerna replied. “Do your parents know about it?” “No,” said Prerna. “It is because of you girls that parents don’t want their girls to go to college. Did you not think of them? How could you submit to a man like this?” Since Prerna’s pregnancy was detected on time and the foetus was just four weeks old, she managed to get rid of it through pills. “I felt ashamed later.
Almost guilty that a lot of women cannot have a baby and here I am popping out one,” says Prerna. “I also felt that though this gynaecologist is well-known, she is probably good only for married women. Don’t unmarried women have an anatomy to deserve a medical right?”
Studies suggest that married women also undergo the same problems: confidentiality issues, lack of awareness, and stigma. According to a report published by CEHAT, a research centre that publishes papers on health themes, in the experience of 60 per cent of married women, doctors providing abortions insisted on the husband’s permission prior to the procedure, and 28 per cent said this was true in government and private hospitals.
It should be clear that this is not a mandate under the MTP Act. In 2007, a sessions court in Punjab observed that a woman’s decision to undergo an abortion without her husband’s consent amounted to cruelty and granted divorce to a man who alleged his “figure-conscious” wife did not inform him before terminating her pregnancy. The court’s order declared Devi’s abortion as “illegal” even though a woman is entitled to an abortion without her husband’s permission under the Act.
Dr Suchitra Dalvie of Asia Safe Abortion Partnership and Common Health says, “In addition to being seen as ‘immoral’ and ‘heartless’ it makes women feel even worse than they already do about having an unwanted pregnancy. All this turmoil occurs at a time when a woman needs care, support, and reassurance.”
A case study of rural Maharashtra by Manisha Gupte, Sunita Bandewar, Hemlata Pisal suggests that 75 per cent of the rural women believe that medical abortion is different and more difficult than delivery. They referred to it as “washing the bag” or “emptying the bag”. Most of the respondents did not know that it took less than three hours and instead estimated it to be 24 hours or more.
A few women also mentioned and preferred local methods, such as inserting the roots of certain plants, still wet with sap, inside the cervix. In their perception, the root eventually “comes out with the whole thing”, which may take just a few hours or a day or more. “The husband who keeps impregnating us and forces us to carry babies one after the other, refusing to use contraception or allowing us to use either, will never get to know about this,” a woman was quoted saying during the survey.
Dr Apurva Gupta, a gynaecologist in Delhi, says these methods are highly unsafe. “A lot of women had to eventually undergo a hysterectomy due to infection. Quick-fix methods come in handy in the society we live in. It’s high time society treated abortions as a reality.” While an MTP procedure is free, additional costs like travel and post-abortion care are not. A surgical evacuation at a private clinic may cost up to Rs. 10,000 excluding post-abortion care, according to Dr Gupta.
Most health insurance companies in India, except employees of the organised sector, the ESIS, CGHS, and the Railway Health Scheme, do not cover the cost of abortion. Health insurance companies discriminate against women in India, keeping MTP procedures completely out of the ambit of the health policy.
This continues unquestioned and is deemed unimportant by both the government and private players. Kanti, 26, an ad-hoc teacher in Delhi University, detected her pregnancy within a week of missing her first periods. She and her partner visited the Aruna Asaf Ali government hospital at Rajpur road, in the vicinity of Delhi University. “‘Miss or Mrs.?’ the receptionist at the registration centre asked me. I replied Miss. He scanned me and my partner. This when till this moment, I had only mentioned that I want see a gynaecologist,” she remembers.
The doctor, a woman in her mid-50s, examined her. “The linen on the examination table was spotted. It freaked me out.” After examination, Kanti was told to collect her urine sample. “The toilet was so littered and filthy that I threw up. I stepped out and left with my partner,” says Kanti. “I have always opposed privatisation of health care. I almost felt guilty consulting a private doctor and going ahead with a private clinic for my abortion.” Similarly, Vandana, 39, a domestic maid, originally from Kharagpur, West Bengal, and now settled in Delhi, chose a private clinic over the government hospital for her 20-year-old daughter’s abortion.
Vandana’s daughter Chaitra got pregnant within two months of her marriage. “I convinced her and her husband to drop it since there was no source of income for them,” Vandana says. “It’s been over a year since my neighbour underwent an abortion in the Madan Mohan Malviya government hospital and she is still being treated for infections. That’s why I took her to a private doctor.” Chaitra underwent a safe abortion and began working as a cook in a South Delhi household to support herself and her husband two weeks after. Both cases are telling.
Even when government MTP centres provide abortion services free of charge, clean toilets, non-judgemental environment and quality services play a very important part in mushrooming private health care and the government’s complete surrender to it instead of pulling up its socks. Abhijit Das, the director of the Center for Health and Social Justice (CHSJ) in New Delhi, refers to morning-after pills whose sales have increased by 250 per cent compared to last year in India.
He says, “They pushed iPills as an easy way to avoid pregnancy after the act, and so men could easily coax women into having unprotected sex. Such promotion furthers patriarchal values by allowing men to assume positions of power within a sexual relationship.”
Even tools to detect a pregnancy, like the newly-launched pregnancy kits, cost at least Rs. 50. Says Dr Apurva Gupta, “Why is the state not providing these kits free of cost at MTP centres? How many socio-economically dependent women can afford it?”
In a society, where women are raised to believe that becoming a mother is a social imperative, the physical, psychological and socioeconomic outcomes of abortion remain similar if not same for women across classes and matrimonial status. And discussions about abortions fail to evolve.
As Prerna puts it, “You have to first try to bury it and then forget about it. If you manage this much, it’s more than enough.”
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