The Medical Termination of Pregnancy (MTP) Act in India came into existence in 1971. It was amended in 2003 to facilitate better implementation and increase access for women especially in the private health sector. However, even four decades after the Act came into effect, unsafe abortions are a reality.
Making out a strong case to amend the Act to increase the availability of safe and legal abortions in India, all stakeholders argue that unsafe abortions still continue to outnumber safe and legal abortions in the country. Unsafe abortions contribute to eight per cent of the total maternal deaths and unaccounted figure of morbidity.
These maternal deaths and morbidities can be addressed through expanding the base of safe abortions, more so keeping in mind the medical advancements. Proposed amendments have been under the consideration of the Ministry of Health and Family Welfare for the past seven years. However, nothing concrete has come out due to the fear of “misuse of liberal abortion law for sex selective abortions.”
One of the major amendments calls for expanding the base for medical termination of abortions by including midlevel providers in conducting the procedures, particularly during the second trimester, and certification for allowing the abortion by one provider as against two, as is the case now.
In the backdrop of shortage of doctors, certification by two service providers — two gynaecologists or two MBBS doctors with requisite training to conduct abortion or a gynaecologist and one MBBS doctor with requisite training — to allow termination of pregnancy often acts as a barrier for women wanting abortion. The issue is more critical in the rural areas where there is an acute shortage of a gynaecologist even at the Community Health Centres. The system therefore forces women to go for unsafe procedures.
Experts make their argument stronger by quoting the 2011 census figures; close to 70 per cent of people live in 6,41,000 villages. Qualified doctors are primarily available in urban areas rather than rural areas.
The recent national level facility survey report (IIPS, 2005) highlights that only 15 per cent of the Primary Health Centres across the country have at least one doctor who has received MTP training. This implies that 2.24 lakh rural population have access to only one MTP trained doctor.
The facility survey 2003 highlights that while 60 per cent of PHCs are equipped with MTP equipment, only 6 per cent of PHCs offer safe abortion services. One of the primary reasons for this is the non-availability of trained providers.
Even if one trained doctor is available at all PHCs across the country and offers MTP services, the number of women served would be 15,000 to 20,000. This would still not be adequate to make safe services available to women.
There is global evidence to show that “trained mid-level providers can perform manual vacuum aspiration safely, and provide medical methods of abortion” and that doing so “can help ensure appropriate service availability and accessibility without compromising safety” (WHO technical consultation 2003).
Studies in India have shown that MVA can be provided with equal safety and effectiveness by nurses and physicians. Shireen Jejeebhoy of Population Council in a study in August 2011 concluded that medical abortion can be as safely and effectively provided by Ayurveda physicians and nurses as physicians with MBBS qualification.