Medical abortion (MA) is a method of termination of early pregnancy using a defined combination of drugs. Recognised as a very safe technology, it is the preferred choice of women across the world. MA was approved by the Drug Controller General of India in 2002 as a Schedule H drug; it is not an over-the-counter medication. However, it is estimated that annually, between 6-8 million women attempt to terminate their pregnancy themselves by sourcing the drugs from chemists without a prescription. Despite abortion being legal in the country and concerted efforts being made by the public health system to improve abortion care, it is worth asking why women take recourse to self-use of MA to terminate an unwanted pregnancy.
For women in India, access to abortion has been marred by extreme stigma, lack of awareness about its legality, unavailability of safe services near the community, and high costs charged by providers. Unsafe abortion practices were the third largest contributor of maternal deaths in India. However, over the last decade, women who cannot access safe and legal services have moved to self-use of MA — perhaps a better option than resorting to life-threatening means.
From the field
Medical and public health experts, alarmed by the self-use of MA by women, provide anecdotal evidence of the high number of women reaching health facilities with incomplete abortions/post-abortion complications. Usually, incorrect self-use of MA leads to excessive bleeding, as in spontaneous abortions, and requires completion of an abortion by a trained provider. There is no doubt that women who receive MA under supervision of a trained provider are less likely to have any complications at all, but it is important to note that complications following self-use of MA are far less and less severe than those encountered during the earlier decades. This is shown in the drop in maternal deaths and injuries due to unsafe abortions, and primarily by the virtual disappearance of women presenting themselves with peritonitis, septicaemia, septic shock, damaged intestines hanging through a perforated uterus — severe complications that require major abdominal surgeries and even removal of the uterus.
Given the nature of MA, the World Health Organisation’s task-shifting guidelines on abortion recognised that self-assessment and self-management of MA can be empowering for women and help to triage care. It suggests that if women have the information and access to a health-care provider, they can safely self-manage MA and assess completion of abortion in the first trimester even in low literacy, low-resource settings.
Access to safe abortion
We need to realise and acknowledge that women self-use MA not because they do not want safe and legal abortion services, but on account of our health system not yet offering them the services they need. Till we can make women-centric comprehensive abortion care services available across the country, we need to accept the inevitability of women choosing to self-use MA. Given the rapid progress of technology, is it not our responsibility to break down legal, operational and societal barriers for access to safe abortion?
These include expanding the base of legal providers of abortion to enable wider access to safe services; allowing for training of providers only on MA; withdrawing unnecessary restrictions on chemists that lead to unavailability of MA drugs; and training certain cadres of service providers to effectively manage post-abortion complications. Till the time systemic hurdles are crossed to make any of these possible, we must at least ensure that women who self-use MA have access to adequate information and systems for supportive care including identifying danger signs, access to health facilities if required, and, most importantly, post-abortion contraception.
Vinoj Manning is Executive Director, Ipas Development Foundation
