As two women public health practitioners who have studied and worked in India and the United States, we voice our solidarity with women in both countries at this precarious moment for abortion rights.
Our public health journeys started with witnessing maternal deaths in India. One of us, on her first clinical rotation, saw a woman die of sepsis, infection in the blood, due to an unsafe backstreet abortion. And the other, during her rural health internship in Uttar Pradesh, witnessed a pregnant woman die on a wooden hand-pulled cart because she was unable to reach the hospital in time. The images of these two women with their swollen abdomen and pale, dying faces still haunt us, as we reflect on the privileges we enjoy as women belonging to a certain class and caste in India.
Women, pregnant people and transgender persons in India struggle every day to exert their choice about birthing and their bodily autonomy. Yet, despite this bleak reality, netizens on social media in India claim that the country is more progressive than the U.S. on abortion rights because we have the Medical Termination of Pregnancy Act, 1971 (“MTP Act”). Such a self-congratulatory attitude is neither in good faith nor is it factually correct.
According to the World Health Organization, six out of 10 of all unintended pregnancies end in induced abortion. Around 45% of all abortions are unsafe, almost all of which (97%) take place in developing countries. As per a nationally representative study published in PLOS One journal in 2014, abortions account for 10% of maternal deaths in India.
The recent round of the National Family Health Survey 2019-2021, shows that 3% of all pregnancies in India result in abortion. More than half (53%) of abortions in India are performed in the private sector, whereas only 20% are performed in the public sector — partly because public facilities often lack abortion services. More than a quarter of abortions (27%) are performed by the woman herself at home.
In another a fact-finding study published in The Lancet in 2018, 73% of all abortions in India in 2015 were medication abortions, and even though these may have been safe — many of these are illegal as per the MTP Act, if they occur without the approval of a registered medical practitioner. Another 5% of all abortions were outside of health facilities with methods other than medication abortion. These risky abortions are performed by untrained people under unhygienic conditions using damaging methods such as insertion of objects, ingestion of various substances, abdominal pressure, etc. A recent study found that sex-selective abortions in India could lead to 6.8 million fewer girls being born between 2017 to 2030.
Many may be unaware of these disturbing statistics and facts. But we all know of at least one adolescent girl among our family or friends or networks who had to travel to another city in order to find a ‘non-judgmental’ obstetrician or who had to arrange money to access abortion in the private sector. Or, we may have heard of someone who has aborted a female foetus because the family wanted a son; or know of a mother who escaped the pressure of such forced abortion because she did not want to lose her pregnancy.
The MTP Act, first enacted in 1971 and then amended in 2021, certainly makes ‘medical termination of pregnancy’ legal in India under specific conditions. However, this Act is framed from a legal standpoint to primarily protect medical practitioners because under the Indian Penal Code, “induced miscarriage” is a criminal offence. This premise points to a lack of choice and bodily autonomy of women and rests the decision of abortion solely on the doctor’s opinion. The MTP Act also only mentions ‘pregnant woman’, thus failing to recognise that transgender persons and others who do not identify as women can become pregnant.
Moreover, the acceptance of abortion in Indian society is situated in the context of population control and family planning. But, most importantly, after more than 50 years of the MTP Act, women and transgender persons face major obstacles in accessing safe abortion care.
Editorial | A small step: On medical termination of pregnancy law amendments
These are seven examples: First, they may not even be aware that abortion is legal or know where to obtain one safely; second, since the MTP Act does not recognise abortion as a choice, they need the approval of medical professionals even in the first few weeks of the pregnancy; third, unmarried and transgender people continue to face stigma and can be turned away from health facilities, forcing them to resort to unsafe care; fourth, mandatory reporting requirements under the Protection of Children from Sexual Offences Bill (POCSO), 2011 law against child sexual offences, impact privacy and hinder access of adolescents to safe abortion services; fifth, many are still coerced into agreeing to a permanent or long-term contraceptive method as a prerequisite for getting abortion services; sixth, health-care providers may impose their own morality by insisting on ‘husbands’ or ‘parental’ consent for abortion. Even women seeking abortion care in health facilities are often mistreated and not provided medications for pain relief; seventh, despite laws prohibiting sex determination, the illegal practice persists. The mushrooming of unregulated ultrasound clinics in India continues to facilitate the illegal practice of sex determination, resulting in unsafe abortions and female foeticide.
It is a testament to class and caste divides when netizens talk of being ‘progressive’ when, 50 years after the MTP Act, women continue to die due to unsafe abortions. Passing one law and assuming the job is done is far from “progressive” when so many face a lack of access, systemic barriers, social norms and cultural preferences, and even criminal liability.
One law is insufficient
There is an urgent need in our country to shift the discourse on abortions from just being a family planning and maternal health issue to one of a sexual health and reproductive rights issue. The situation in India shows that one law alone is insufficient and we must raise the bar on reproductive justice. We must improve our health systems to ensure good quality and respectful abortion care. As the focus on abortion rights in the U.S. rages, we call upon all to self reflect and to stand in solidarity with people in the U.S. and other places where reproductive rights are in jeopardy. Reproductive injustice anywhere is a threat to the lives of people everywhere.
Dr. Sonali Vaid (@sonalivaid) is a physician and a public health professional. She is the founder of Incluve Labs, an organization working to improve the quality and safety of health care. She is a graduate of Harvard T. Chan School of Public Health and is an Aspen New Voices Fellow. Dr. Sumegha Asthana (@sumeghaasthana) is a physician and health systems researcher. She is currently a postdoctoral researcher at Georgetown University. She holds honorary positions at the Institute for Public Health Bengaluru, India and Queen Mary University, London. She is the co-founder of the India chapter of Women in Global Health