How COVID locked gateways to abortion and left millions of women at risk

During the lockdown, when 24-year-old Rukmani* discovered she is pregnant for the fifth time, she decided to terminate it. Rukmani, a resident of Toyra village in Chakradharpur district of Jharkhand, got herself admitted to a hospital at the district headquarters, but left on the fifth day after not being attended to. During the four days, she waited for a health provider to attend to her, but in vain as all were occupied attending to COVID-19 patients. When she visited another hospital, she was told that induced abortion services are not available and that only emergency services were being provided. Much against her will, she returned home and decided to continue with her pregnancy as she had no other option.

Millions of women in India like Rukmani were left with no option, but either to continue with unintended pregnancy or to go for unsafe abortions during the nationwide lockdown due to COVID-19, which left healthcare providers and hospital staff with little time for non-COVID patients, says a study carried out by Ipas Development Foundation (IDF), an organisation working towards strengthening access to safe abortions in India.

The findings of the study reveal how maternal health has been compromised and all non-COVID requirements including medical termination of pregnancy been pushed to the back burner during the lockdown. According to the study, 1.85 million abortions have been compromised during the past three months of lockdown in India – 47 per cent of the estimated number of abortions.

Reduced access to drugs

“It is estimated that 42,000 abortions happen a day in India in normal times. The lockdown disrupted the supply chain of medical abortion drugs, reduced patients’ accessibility to hospitals and clinics as well as to transport services,” Dr Sushanta Kumar Banerjee, the Chief Technical Officer, Research and Development with IDF told The Federal.

According to the report, of the 1.85 million compromised abortions, 1.5 million (80 per cent) have been compromised due to the decrease in the sale of drugs. The supply chain of drugs was severely disrupted and access to chemists cut down either due to restrictions upon mobility or closure of shops.

The remaining 20 per cent of abortions has been attributed to facility-based abortions- 16 per cent through private health care and four per cent through public health care institutions. As most of the hospitals in the public health care system have been changed into COVID-care hospitals, access to non-COVID services was curtailed.

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“It is well acknowledged that due to stigma attached to abortions, women or their partners avoid their neighbourhood chemist shops and prefer a more distant/less frequented outlet for buying medical abortion drugs. With restrictions in transport facilities, their ability to access the outlet of their choice is compromised,” says Dr Banerjee.

These conclusions were drawn by calculating the percentage reduction in abortion access at different points of care at different time periods. The various sources of information include public and private health care services and pharmaceutical companies with their data of drop in the sale of medical abortion (MA) drugs.

The survey has been conducted in 509 public health care facilities and 52 private service providers such as clinics, nursing homes and hospitals, across eight districts.

Hospitals shut doors

Nearly 300,000 abortions (16 per cent of the 1.85 million) have been compromised at private health facilities – this is 80 per cent of the total facility-based abortions. Overall, the volume contributors are nursing homes (51 per cent), followed by private hospitals (28 per cent) and private clinics (21 per cent). The research team of IDF explains that this may be attributed to lack of preparedness and resources for COVID-19, particularly unavailability of protection gear for service providers and the lack of mandatory COVID-19-testing arrangement and other patient care arrangements.

Access to nearly 80,000 abortions or four per cent of the total 1.85 million abortions have been compromised at public health facilities. The greatest reduction is seen in higher-level facilities such as district hospitals and above at 60 per cent, followed by Community Health Centres (24 per cent) and Primary Health Centres (17 per cent). A large number of higher-level facilities including medical college hospitals and district hospitals were converted to dedicated COVID hospitals. Re-deployment of medical staff for COVID-related work has resulted in curtailing the abortion service in the non-Covid hospitals as well.

“Since the higher-level facilities are located at district headquarters or the main town, women living in interior areas are not able to access them due to limited transport facilities,” says Akanksha Sharma, manager, Strategy and Development, IDF.

Logistic hurdles during first 40 days

In addition, the mobility restrictions due to transport for support staff, unavailability of essential drugs and commodities, and risk aversion are other key factors.

“There is a fourfold drop in the first two phases of the lockdown,” says Shankar Narayanan, the managing director of PSI India Private Ltd, a social enterprise working towards strengthening the access to MA and contraceptive drugs and devices. Narayanan says the disruption in the supply and distribution was severely affected for the 40 days of the lockdown. “Unlike lifesaving medicines, the chemists do not stock abortion drugs in a huge quantity. Hence there is a huge gap in demand and supply,” he adds.

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It is also understood that more than half of the total abortions that are unlikely to take place (nearly one million) are during the first 40 days of the lockdown period, as the whole country was under strict restrictions during this period.  The study says the improvement in abortion access with successive time periods due to relaxations in government guidelines – percentage of women with compromised abortion access is expected to decrease from 59 per cent in the first period (lockdown one and two) to 33 per cent in the recovery period.

Just the tip of the iceberg

What is the impact of women being unable to access abortion services?  “The chances of women opting for unsafe abortion is very high, this would have a serious impact on their physical and mental health. Another implication is that women are forced to continue with unintended pregnancy like that we have seen in the case of Rukmani,” says Akanksha, one of the three authors of the study.

However, in a country like India where medical termination of pregnancy is practiced discreetly, no statistics would reflect the actual volume of abortions. Because of the social stigma that prevails, even legally married couples prefer to keep it confidential.

In States like Maharashtra, Rajasthan and Haryana, around 80 per cent of medical abortions drugs are being sold unbilled. A marketing professional with the pharmaceutical industry told The Federal on conditions of anonymity that the data available in the social domain would be very inadequate. “Since the implementation of POCSO Act, this has been increased. As the drugs would not be available for minor girls who are pregnant without a valid FIR, people buy it unbilled,” he says.

“The lockdown has had a major impact on access to abortion as in its initial phases, access to all elective surgeries was considered non-essential and abortion was understood to be included,” says Anubha Rastogi, a human rights lawyer based in Mumbai.

“The ministry came out with a list of essential services that were to be carried out in spite of the lockdown and thankfully abortion was included. However, in most cases, access to abortion is preferred in an unknown setting where the woman is not known to the doctor or the chemist. This was not possible due to restricted movements in the lockdown and the entire family being at home,” Anubha adds.

She also said that this access is further limited for pregnancies which are unwanted and not the result of a relationship accepted by society. It is worse if the pregnant girl is below 18.

Abortion has not yet been recognised as a matter of right. “If it is recognised as a woman’s right, then the state has a corresponding duty to accomplish it. Not only abortion, but even healthcare also is not a matter of right in India,” says Prachinkumar Ghodajkar, assistant professor at the Centre for Social Medicine and Community Health, Jawaharlal Nehru University.

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However, the proposed amendment to the Medical Termination of Pregnancy Act, 1971 widens the scope of one’s right to go for medical termination of pregnancy. The permitted period of gestation for abortion is extended to 24 weeks (from 20 weeks) by this amendment.

Ghodajkar agrees with the findings of Ipas Foundation. “The MA drugs are available from the chemists only on prescription. When there were no medical services available, how could have these women managed to get prescriptions,” he asks.

“Abortion is not considered a right in the current legal framework, even though court judgements like the right to privacy judgement recognise a woman’s right over her body as bodily autonomy,” says Anubha Rastogi.

Rastogi says that the current bill does not address this issue. “There has been a consistent demand to have abortion as a right at least up to 12 weeks, in previous versions of the Bill this was included but not in the 2020 bill which has been passed by the Lok Sabha,” she adds.

One’s need for the medical termination of pregnancy can’t wait till the lock down being lifted. A huge spike in the number of unintended pregnancies to be expected by which the quality of the life of millions of women also would be compromised.

(*name changed)