What You Need To Know About Abortions in India

-Dr. Anjali Mediboina, House Surgeon, ASRAM

Disclaimer: The objective is not to hurt any sentiments or be biased in favor of or against any particular person, society, gender, creed, nation or religion. Kindly do not browse through the article if you believe that certain kinds of content may be offensive to you.

Abortion is theoretically defined as the termination of pregnancy before the fetus becomes viable, i.e. capable of living independently. As of 2021, in India, this period of viability has been fixed as 20-24 weeks of gestational age, when the fetus weighs approximately 1000g^[1].

In the medical field, abortions are classified into two types: Spontaneous and Induced. Spontaneous abortions, or miscarriages, as they are more commonly known, occur without interventions, while induced abortions are deliberate terminations of pregnancies. These have been organized into three-tiers by the WHO: 

• Safe: Abortions provided by a health-care worker and methods recommended by WHO)

• Less Safe: done by trained providers using non-recommended methods or using a safe method (e.g. misoprostol) but without adequate information or support from a trained individual.

• Least-safe abortion: done by a trained provider using dangerous, invasive methods^[2]. 

There are several methods of induced abortion. Broadly, they can be categorized into Medical and Surgical methods. These methods have been described in detail in the WHO Clinical Practice Handbook for Safe Abortion, which you can read here.

• Medical Methods: These methods of  abortion are recommended to be used from 9 weeks to 12 weeks of gestational age. 
  • The WHO recommends Misoprostol and Mifepristone or Misoprostol alone in various doses and routes, according to the gestational age. 

• Surgical Methods:
  • ≤12-14 weeks – manual/electric vacuum aspiration 
  • >12-14 weeks – dilatation and evacuation^[3] 

Until 1971, abortions in India were considered a crime under the Indian Penal Code 1860 and the Code of Criminal Procedure 1898, except when performed to save the life of a pregnant woman. In 1971, the Medical Termination of Pregnancy (MTP) Act was passed by the Indian Parliament and came into force from April 1, 1972 (in all states except Jammu & Kashmir, where it came into effect from November 1, 1976)^[1]. 

The MTP Act was amended in 2021, with some key changes: 

Key provisions to the MTP Amendment Act, 2021^[4]

While these amendments were historic and expanded access to abortions, there were some disputes brought up by Devika Nair, Shruti Singhi and Sumati Thusoo in an article for The Wire^[5]:

• The Act stipulates that the abortions should only be performed by doctors with a specialisation in gynecology or obstetrics. 

The problem here, as said by Nair et al., is that there are only a total of 1,351 OB-GYN practitioners in the Community Health clinical in rural India. Data from the National Health and Family Survey 4 also shows that 47% of abortions in India are carried out by nurses, Auxiliary Nurse Midwife (ANM), Lady Health Visitors (LHV), Dais or family members ^[5]. 

• According to Indian law, a female under age of 18 years cannot consent to an abortion. She can only do so with the consent of her parents/guardians. Furthermore, under Section 375 of the IPC, sexual intercourse with a minor, irregardless of consent, is considered to be statuatory rape. And, according to the Protection of Children from Sexual Offences (POCSO) Act 2012, under sections 19 and 21, sexual offences against a minor must be reported to the police. Thus, if an underage girl were to approach a doctor for an abortion, the doctor is legally bound to report it as penetrative sexual assault^[5,6]. 

• The Act allows abortion upto 24 weeks of gestational age; beyond that, abortion is only allowed in cases where the Medical Board diagnoses substantial fetal abnormalities. Therefore, for abortion beyond 24 weeks without any fetal abnormalities/due to rape/grievous harm to the mother, it becomes a medico-legal matter, creating delays for the woman and making it even more difficult and dangerous to abort^[6]. 

• Moreover, the language in the MTP Act is still exclusionary; by using the terms “pregnant woman” and “female”, transwomen are excluded, making abortion services still inacsessible to the LGBTQ+ community^[7]. 

India is making progress, albeit slowly, but surely and steadily. There is still a long way to go but, comparatively, the state of reproductive health in our country is in a much better place when compared to others.

One thing must be kept in mind: there is no such thing as banning abortions; rather safe abortions will be banned. Making abortion illegal or inaccessible will only make people opt for unsafe abortions instead, further contributing to global maternal mortality rates.

References:

1. Park K. Park’s Textbook of Preventive and Social Medicine. 25th ed. 2020.

2. Ganatra B, Gerdts C, Rossier C, Johnson Jr BR, Tunçalp Ö, Assifi A, Sedgh G, Singh S, Bankole A, Popinchalk A, Bearak J. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet. 2017 Nov 25;390(10110):2372-81.

3. Clinical practice handbook for Safe Abortion [Internet]. 2014 [cited 25 June 2022]. Available from: https://apps.who.int/iris/bitstream/handle/10665/97415/9789241548717_eng.pdf

4. Medical Termination of Pregnancy (MTP) Amendment Act, 2021 [Internet]. Drishti IAS. 2021 [cited 25 June 2022]. Available from: https://www.drishtiias.com/daily-updates/daily-news-analysis/medical-termination-of-pregnancy-mtp-amendment-act-2021

5. Nair D, Singh S, Thusoo S. Why Amendments to Medical Termination of Pregnancy Bill Don’t Go Far Enough [Internet]. The Wire. 2021 [cited 25 June 2022]. Available from: https://thewire.in/health/medical-termination-of-pregnancy-amendment-bill-women-abortions

6. Sibal S. Amendments We Should Be Asking For in the Medical Termination of Pregnancy Bill [Internet]. The Wire. 2020 [cited 25 June 2022]. Available from: https://thewire.in/women/medical-termination-of-pregnancy-bill-amendments

7. Bardhan S. The Abortion Amendment Shows That The Language Of Indian Public Policy Is Exclusionary [Internet]. Youth Ki Awaaz. 2021 [cited 25 June 2022]. Available from: https://www.youthkiawaaz.com/2021/04/exclusionary-language-of-public-policy/

8. Fromer MJ. Abortion ethics. Nursing outlook. 1982 Apr;30(4):234-40.

9. Bhaumik A. US Supreme Court Overturns Roe v. Wade Ending 50 Years Of Federal Abortion Rights [Internet]. Livelaw.in. 2022 [cited 25 June 2022]. Available from: https://www.livelaw.in/top-stories/us-supreme-court-overturns-roe-v-wade-ending-50-years-of-federal-abortion-rights-202282