INDUCED ABORTION IN INDIA
Shweta Rana Chauhan*
In a society, a woman who is pregnant is pressurized to abort and
one who is not pregnant is pressured to control her fertility. The women insocieties such as that found in India do not have the choice to remainsingle and, having gotten married, they cannot choose when to have thesexual relations that make them pregnant. Nor is the choice to continuethe pregnancy or not theirs. In India, today many pregnant women maketheir “only choice” - induced abortions - which may be neither legal norsafe. Free access to abortion is a woman’s right and a major demand ofthe feminist movement. It has being observed that abortions are damagingthe health of women. In a patriarchal society where women have norights over their bodies, and population control policy is being forced,abortions and abortion services add to being one more instrument for theexploitation of women. To be able to participate effectively in political andsocial processes, women must have access to information, choice, andcontrol over reproductive technologies. However, as techniques ofmedically monitoring and managing labour became available, methods ofinduced abortions are developed.
ABORTION LAWS AND THE ABORTION SITUATION IN
FAMILY PLANNING LEGISLATION
In the First Five Year Plan (1951-1956), a family planning
programme was introduced to improve the health of women and children.
It needs to be noted that the fertility regulation programme of theInternational Planned Parenthood Federation was designated as the birthcontrol programme. However the Indian Planners had the welfare of thefamily in mind and hence the programme was called Family Planning.
The programme was a part of Maternal and Child Health (MCH) underthe Ministry of Health. Since the Third Plan (1961-1966) was instituted,
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due to pressures from the international agencies, the objective of theprogramme has become a reduction in the birth rate.
The year 1965 saw a nationwide famine. There was a shortage
of rain in the following year as well. India experienced a serious foodcrisis and the government of United States discussed the food shortage inthe country. The 1961 census showed that the rate of growth of the Indianpopulation continued to be high and it was believed that the distribution ofcontraceptive methods such as a diaphragm and jelly, foaming tablets, andcondoms by the family planning clinics was not effective in reducing thebirth rate. The discussion between the government of India and the UnitedStates authorities therefore led to the introduction of methods such as theIUD, the use of which was unrelated to the sexual act, was providercontrolled, and was expected to be more effective in bringing down thebirth rate. The people, who accepted these methods, as well as the staffmembers providing the services, received financial incentives. Theincentives to the participants of the camps were larger. Group pressuresand mass motivation worked at these camps. The largest camp was heldin July of 1971 at Ernakulum in Kerala. The number of men undergoingvasectomy in this camp was 62,913 (Krishnakumar, 1974). The introductionof the camp approach demonstrated an anxiety about the populationproblem. The achievements of the programme were due to what came tobe informally called “coercive persuasion.” The States that took hardestline were Maharashtra and Tamil Nadu. The camp approach was originallydeveloped by the officials of the government of Maharashtra. In September,1968, Maharashtra also introduced a scheme of disincentives. In 1976 theState introduced a bill for compulsory sterilisation of couples with three ormore children.
Abortion in India was legal only to save the life of the mother.
The provisions of the Indian Penal Code placed India in the category ofthose countries with highly restrictive abortion laws. Section 312 of theIndian Penal Code provided: Whoever voluntarily causes a woman withchild to miscarry shall, if miscarriage be not carried in good faith for thepurposes of saving the life of the woman, be punished with imprisonmentof either description for a term which may extend to three years, or withfine or with both, and if the woman be quick with child, shall be punished
with imprisonment of either description for a term which may extend toseven years, and shall also be liable to fine.
Further provisions of the Penal Code provided severe penalties
for abortions performed without the woman's consent, and for infanticide.
Until 1971, therefore, abortions in India were governed by the Indian PenalCode of 1862 and the Code of Criminal Procedure of 1898. The latterlays down the procedure to try persons violating the substantive law underthe former. The origin of this code was the British Law of the 19th century.
On August 25, 1964, the Central Family Planning Board
recommended that the Ministry of Health create a committee to study thequestion of legislation on abortion. The recommendation was adopted Latein 1964, and a committee was constituted, with representatives from avariety of Indian public and private agencies. The committee - calledShantilal Shah Committee - issued its report on December 30, 1966. Thegovernment decided to liberalise the abortion laws and passed the MedicalTermination of Pregnancy Act (MTP Act of 1971). The terminology wasspecifically designed to make it easy to get the law approved by theparliament. The law was passed as a health measure to protect womenfrom the hazards of untherapeutic abortions. According to the report ofthe Shantilal Shah Committee, the major concern of the Committee wasthe hazards of illegal abortions.
The period since the 1990s has witnessed major changes in the
field of abortion including the adoption of new legislative measures, theintroduction of new technologies and the growing demand for sex selectiveabortion. Some of these developments, such as the recent amendments tothe Medical Termination of Pregnancy (MTP) Act and the introduction ofinnovative abortion technologies, such as the improved manual vacuumaspiration technique and medical abortion, are expected to increase theavailability of safe abortion services.
Recognizing the failure of the MTP Act of 1972 to make legal
abortions widely available, the government amended the Act in 2002. With
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the amendment, the authority for approval of registration of MTP centreshas been decentralized from the state to the district level. In the year2003, the government introduced a further amendment to MTP Rules whichhas rationalized the criteria for physical standards of abortion facilities --fixing different criteria as appropriate for conducting first-trimester andsecond-trimester abortions. While facilities such as an operation table andinstruments for performing abdominal or gynaecological surgery, andequipments for anaesthesia, resuscitation and sterilization continue to bethe minimum requirements for centres offering second-trimester abortion,the MTP Rules 2003 require a gynaecological or labour table rather thanan operation table and resuscitation and sterilization equipment but notanaesthetic equipments for centres offering first-trimester abortion. Theserules also permit a registered medical practitioner to provide medicalabortion services in the case of termination of pregnancy up to sevenweeks, provided the practitioner has access to a facility for offering surgicalabortion in the event of a failed or incomplete medical abortion. TheReproductive and Child Health Programme launched in 1997 and theNational Population Policy, 2000 have also delineated a number ofstrategies to increase the access to safe abortion at the primary healthcare level. Amendments have also been introduced in the PrenatalDiagnostic Techniques (Regulation and Prevention of Misuse) (PNDT)Act of 1994. This was necessitated as the PNDT Act had failed to curbthe practice of testing for sex determination and consequent sex-selectiveabortion in the country. With the recent amendment to the PNDT Act,preconception and pre-implantation procedures for sex selection are bannedin the country. The Amendment stipulates compulsory maintenance ofwritten records by diagnostic centres/ doctors offering sonography service.
ABORTION PRACTICE IN INDIA
MEDICAL TERMINATION OF PREGNANCY (MTP) IN INDIA
Legal Status of Abortion
The Medical Termination of Pregnancy Act, approved in India in
1971 and enacted in 1972, permits abortion (or MTP) for a broad rangeof social and medical reasons, including: to save the life of the woman; topreserve physical health; to preserve mental health; to terminate a
pregnancy resulting from rape or incest and in cases of fetal impairment.
Contraceptive failure also is sufficient ground for legal abortion (UnitedNations 1993).
Barring medical emergencies, legal abortions must be performed
within the first 20 weeks of pregnancy and must be performed by aregistered physician in a hospital established or maintained by thegovernment or in a facility approved for the purpose by the government(Mathai 1998). For abortions taking place between twelve and twentyweeks of pregnancy, a second opinion is required except in urgent cases.
Women must grant consent prior to the performance of the abortion. Inthe case of minors (defined as under age 18) and mentally retarded women,written consent of guardian is necessary (United Nations 1993). Critics ofthe abortion law admit that when it was introduced it was a greatachievement for women’s health. Nearly 30 years later, the law andassociated rules and regulations are considered overly medicalised andbureaucratic, and as such, not oriented toward women’s right to accesssafe and legal abortion services. The law offers substantial protection formedical providers. Note that “doctors . . . receive blanket indemnity underthe MTP Act - instead of functioning as for other surgical procedures andtaking the consequences of any default or neglect.”
Inadequate Legal Abortion Service Provision
Despite the broad range of indications for legal abortion, illegal
and unsafe abortions are common in India for many reasons. Womenaccess care from uncertified providers because certified providers aregeographically inconvenient; staff at certified facilities tend to not respectwomen’s confidentiality; because women are unaware of certified facilities;because Registered facilities often do not have a trained provider and/orthe necessary equipment to provide safe abortion services; and manywomen are unaware that abortion is legal and publicly available. Cost,coercion, moral dilemma, late knowledge of pregnancy and unmarried statusare additional reasons women seek abortion from illegal providers. Someproviders do not approve of elective abortion and scold the client as theyprovide treatment; the pressure to accept sterilization or other long-termcontraception after an abortion discourages women from using registeredfacilities. When the reason a woman elects to abort a pregnancy is not
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legally sanctioned, for example for a sex-selective procedure; or whenthe procedure is highly socially stigmatized, for example to terminate anextramarital pregnancy, women must access the more confidential servicesof uncertified abortion providers.
Illegal Abortion - Providers and Methods
Because of the barriers preventing women from accessing MTP,
women access abortion from unregistered, uncertified providers. Abortionservices from unregistered providers range from completely safe - providedby trained medical doctors in appropriate facilities - to life threatening.
Uncertified abortion providers can include trained medical doctors andnurses in hospitals, Auxiliary Nurse Midwives (ANM), ayurvedics,homeopaths, dais or traditional birth attendants, family health workers,village health practitioners, pharmacy shop-keepers and village women.
Common methods of inducing abortion include vaginal and oral methods.
Dais use methods such as inserting sticks, herbs, roots, and foreign bodiesinto the uterus to induce abortion. Other vaginal methods include pins,laminaria tents, and Fetex Paste. Rural Medical Providers (RMPs or“quacks”) sell medicines for oral use to induce abortion. ANMs (AuxiliaryNurse/ Midwives) and ISMPs (Indian System of Medical Practitioners)use intramniotic injections such as intramniotic saline and intramnioticglycerine with iodine to induce abortion. Orally ingested abortificants includeindigenous and homeopathic medicines, chloroquine tablets, prostaglandins,high dose progesterone’s and estrogens, papaya seeds with high doseprogesterone’s and estrogens, liquor before distillation, seeds of custardapple and carrots.
Characteristics of women who terminate unwanted pregnancies
The reasons Indian women terminate unwanted pregnancies are
many and varied. Conditions that can lead to a pregnancy being unwantedinclude: financial reasons; already having too many children or having toomany female children; becoming pregnant after too short a birth interval;experiencing health problems during pregnancy; becoming pregnant at anolder age; becoming pregnant soon after marriage; suspecting husband’sinfidelity; having an extra-marital pregnancy and becoming pregnant as aresult of rape are all conditions that can lead to a pregnancy being
unwanted. For most of these conditions, a more proximate determinant ofunwanted pregnancy is lack of access to appropriate contraception. Forsome women, contraception is not an option because of family pressure.
Other women cannot access a contraceptive method appropriate for them.
For unmarried adolescents, contraception is generally not available. Insuch cases, abortion may be the predominant means of birth control.
Contraceptive failure and user failure can lead to unwanted pregnanciesthat can be aborted legitimately in the Indian medical system.
Medical abortion or abortion by orally administered regimens of
mifepristone and misoprostol has recently been accepted worldwide as aneffective and safe option for Induced Abortion: Clinical trials in a numberof countries, including India, have shown that the use of the standardFrench regimen,which includes administering 600 mg of mifepristone duringthe first visit and 400 ?g of misoprostol during a follow-up visit after twodays, combined with a follow-up visit after two weeks, is effective in95% of cases of early abortion (i.e. up to 49 days from the last menstrualperiod) and safe (major complications were reported in only 0.5% ofcases). The Drug Controller of India approved the use of medical abortionin April 2002 given the current situation in India, where abortion-relatedmortality and morbidity are high, medical abortion offers great potentialfor improving the access to abortion and safety, as it does not requireextensive infrastructure and is non-invasive. Further, as the client doesnot need to be hospitalized, medical abortion offers women greaterindependence, control and privacy. However, the potential for misuse is amatter of concern. In fact, although abortion tablets are required to besold by medical prescription and consumed under medical supervision,these pills are reportedly widely available over-the-counter and unsupervisedconsumption is rising.
To give birth to a female child would mean spoiling her life
as well as her parent’s life. So, we felt it was right to abort the
female foetus [27-year-old woman with a Son and a daughter].
“Either you get your abortion before sonography or after, I will
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charge you the Same money but if God hears your wish and the
foetus are found to be male, and then you can escape from abortion.
[41-year-old woman with four daughters narrating her experiences
with a provider]”.
With the introduction of amniocentesis to detect abnormalities of
the foetus, sex determination techniques have been available in India since1975. The expansion of facilities offering sonography in the mid- 1980smade testing for sex determination widely and easily available. Althoughthe government tried to curb the increase in sex selective abortions byintroducing the PNDT Act in 1994, the Act proved to be ineffective inpreventing such abortions.
Sex selective abortion is done for “son” preference. sex-selective
abortion is reported to be a family building strategy to achieve the conflictinggoals of limiting family size and achieving the desired sex composition.
The prevalence of sex-selective abortion is found to be higher amongwomen with one or more living daughters but no living sons. However,some studies report that sex-selective abortion is practised by coupleswho already have a living son or no children. Further, evidence fromqualitative studies indicates that sex-selective abortion is perceived andprojected as an easy alternative to female infanticide, a way to save girlchildren from an unhappy life and a means to prevent dowry payment infuture.
Profile of abortion-seekers
While women of all age groups seek abortion in India, a recent
review suggests that the majority of those seeking abortion are in the agegroup: 20-29 years. A substantial number of adolescents, both Marriedand unmarried, also seek abortion services. The vast majority of womenseeking abortion in India are married.
The Way Forward
There is also a strong need for efforts to promote awareness of
the dangers of unsafe abortion practices and the gestational age at whichsafe abortion can be obtained. Equally important are communication effortsto remove the stigma associated with induced abortion.
Given the uneven distribution of existing facilities, efforts to increasethe accessibility of safe abortion services to hitherto unserved or under-served areas and population groups, including married and unmarriedadolescents, need to be vigorously pursued. The lack of trainedmanpower needs to be addressed by improving training facilities andfacilitating the training of private practitioners. The training curriculumshould include new and safer methods of abortion, including manualvacuum aspiration techniques and medical abortion, as well asemphasise the quality of care elements.
Given the poor quality of existing abortion services in the country,establishing service delivery guidelines regarding technical standardsof service, patient provider interaction, confidentiality, pre- and post-abortion counselling and care is critically needed. All existing MTPfacilities should be regularly monitored and evaluated.
The fact that many women seek abortion services to limit family sizeor space the next pregnancy highlight the importance of improving theaccess to quality family planning services.
Finally, given that women, especially young women, have very littlesay in reproductive and sexual health decisions, including abortion-related decisions, the need for multisectoral activities to raise theWomen’s status cannot be overemphasized.
Abortion has increased in recent years, but significant gaps in our
understanding of the multiple dimensions of abortion-seeking behaviourprevail. The evidence on the prevalence and patterns of abortion is limited,and even the latest available estimates of induced abortion are more thana decade old.
Abortion-related needs and service seeking patterns of many vulnerablegroups including adolescents, and unmarried, divorced or separatedwomen remain less studied and hence there is need for future studiesto focus on these subpopulation groups.
The review highlights that the practice of sex-selective abortion isincreasingly becoming common in many parts of the country. An in-
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depth understanding of the prevalence/incidence and perspectives ofthose involved in decisions on sex-selective abortion, clients ‘profileand experiences, is needed to formulate effective policies andprogrammes to prevent this practice.
The quality of abortion services in the country is generally poor.
The constraints that providers face in providing quality service need to beexplored to design more appropriate interventions. While abortion per seis less studied, the pathways between pregnancy and abortion are evenless explored in India.
ABORTION LAWS AND THE ABORTION SITUATION IN
INDIA- MALINI KARKAL
The Current Scenario in India- K.G. Santhya, PhD
and Shalini Verma, PhD
ABORTION PRACTICE IN INDIA A REVIEW OF LITERATURE-Heidi Bart Johnston.
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