Illustration: Jayachandran/MInt
Illustration: Jayachandran/MInt

Attitudes to abortion putting women at risk of exploitation

Though abortions are legal in India, lack of transparency, social taboos and limited awareness are big hurdles for women with unwanted pregnancies

Mumbai: “Doctor? I never went to a doctor for an abortion," says the 29-year-old, an advertising industry executive based in New Delhi, who discovered in 2009 that she was pregnant.

Her landlady had told her that pills are available in the market for inducing an abortion and she headed to Delhi’s government-run Safdarjung Hospital and asked for help at the pharmacy.

“I am pregnant, what do I do?" the unmarried woman asked the chemist, who handed her some medicines and told her how to take them. She spent just Rs500 on those pills, whose names she can’t remember. The pills worked. It was her first pregnancy.

She is one of the multitude of women who aren’t aware of how to get an abortion done and the legalities involved. According to Delhi-based non-profit CREA, which describes itself as a feminist human rights organization, most Indians are unaware of the basics of an abortion.

“It is really saddening that people here have no idea that abortions are legal in India," said Anubha Singh, programme coordinator at CREA. “We see a major conflation between an abortion and sex-selective abortions (among Indians). There is a lack of understanding and last year (unsafe) abortions were the third highest cause of maternal deaths in India."

CREA has been running a social media awareness campaign called #AbortTheStigma that dispels myths surrounding medical and surgical abortions. It also conducted surveys on attitudes towards abortions among ordinary citizens.

Under the Medical Termination of Pregnancy Act, 1971 (MTP Act), a pregnancy can be medically terminated only by a “registered medical practitioner" at a medical facility (government-owned or private) registered as an MTP centre.

Legally, medical abortions induced by mifepristone and misoprostol tablets are allowed for a pregnancy of up to 12 weeks. Doctors say that most medical practitioners do not allow such abortions beyond the seventh week to make sure that there is no chance of medical complications developing.

Information on clinic locations, services offered and even online access to some reproductive/sexual healthcare services is available on the network’s official website.

Beyond that, until the 20th week, the Act allows surgical abortions under anaesthesia. This must be approved by two registered medical practitioners. Accordingly, there are two kinds of MTP centres—Category A for pregnancy of up to 12 weeks, and Category B for those beyond 12 and up to 20 weeks. Abortions beyond 20 weeks of pregnancy are illegal in India unless approved by a court.

Every local civic body must register and monitor hospitals, clinics and nursing homes that are allowed to conduct an abortion. But a key gap in the system is that a complete list of MTP centres, names of the medical abortion pills and their correct prices are not easily available.

Contrast this with the US, for instance, where Planned Parenthood is a well-known, identifiable network of sexual and reproductive health clinics run by a non-profit with government (and other) funding.

Information on clinic locations, services offered and even online access to some reproductive/sexual healthcare services is available on the network’s official website.

Planned Parenthood also doubles up as a blog to educate people on reproductive health issues including contraception, sexually-transmitted diseases and the psychology of sexual relationships.

In the UK, the National Health Service’s NHS Choices plays the same role.

“People may not know about MTP centres, but then they will go to their local gynaecologist," said Padmaja Keskar, executive health officer of F ward, Municipal Corporation of Greater Mumbai. “In Mumbai, most of these gynaecologists are registered. But you are right—it makes sense to put up a list of MTP centres online, we can try to make arrangements for that. But how will people without internet access get this list?"

Lack of transparency in the system and limited awareness among women with unwanted pregnancies stem from the fact that a stigma is attached to abortions, although they are legal.

Indian society largely condemns pre-marital sex. This results in enormous mental stress on a pregnant, unmarried woman as she deals with the anxiety of getting a safe abortion done and the fear of her family discovering that she was sexually active, according to four unmarried women who had an abortion and were interviewed for this article.

They requested anonymity.

Married women who had an abortion said the problem is either that the family disapproves of the decision to abort a pregnancy or that the family (which has somehow managed to determine the sex of the foetus) compels them to abort a female foetus.

There is a risk of families looking for gynaecologists who are willing to provide sex determination ultrasound tests, and help medically and surgically abort a female foetus.

Census 2011 found the Indian sex ratio to be 939 girls for every 1,000 boys. Now, the central government reckons that will fall further to 898 females per 1,000 males by 2031, according to an April 2017 report titled Youth in India published by the ministry of statistics and programme implementation.

According to data from QuintilesIMS, overall prescriptions of abortion pills in India numbered 359,148 in the financial year 2017, lower than 407,260 in 2016. Five years ago, the prescriptions numbered 343,306.

Controlling female foeticide is one of the key factors that have shaped the legal framework for prenatal sex determination (Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994) and abortions in India. Despite the law, sex-selective abortions continue.

“Doctors, staff at maternity clinics, distributors, pharmaceutical companies and medical representatives of pharma firms are often pulled up by police or local authorities for their likely involvement in a female foeticide case," said a Mumbai-based stockist who supplies prominent pharmaceutical drugs including MTP kits. He requested anonymity. “This is why people in the supply chain refrain from talking about abortion pills."

While researching for this story, Mint spoke to several suppliers and stockists who all refused to talk on record, or even admit they were supplying mifepristone and misoprostol in India.

“Some years back, misuse of these pills to abort a female child was very high," said the Mumbai-based stockist cited above. “There was also some involvement of medical representatives of companies, who in a bid to achieve sales target or make extra money, would try and sell these pills to doctors involved in sex determination or doctors whose clinics are not registered as MTP centres," the stockist said, adding that such misuse had gradually declined.

Law enforcers in the system also blame this on a nexus between medical representatives and doctors.

“GPs (general practitioners) are also prescribing these pills and there may be many who are not registered," said Asha Advani, special officer for family welfare and maternal child health at the Municipal Corporation of Greater Mumbai F South Ward. “MRs (medical representatives) also go to these GPs, give them samples, even sell the pills to them at a lower price. Frankly, companies should not be going around giving pills to doctors who are not registered as an MTP centre."

According to data from healthcare information and services provider QuintilesIMS, overall prescriptions of abortion pills in India numbered 359,148 in the financial year 2017, lower than 407,260 in 2016. Five years ago, the prescriptions numbered 343,306.

According to this data, Mankind Pharma Ltd’s Unwanted Kit, Cadila Healthcare Ltd’s Mifegest Kit, Macleods Pharmaceuticals Ltd’s Insta Kit, and Aristo Pharmaceuticals Pvt. Ltd’s Mifty Kit are the top selling brands of abortion pills. In a market worth nearly Rs400 crore, Mankind Pharma and Cadila Healthcare have a market share of 25% each.

Cadila Healthcare and Mankind Pharma did not respond to emailed questionnaires.

“Distributors supply the abortion pills only when they have a written order from doctors or the maternity clinics or hospitals," said the Mumbai-based stockist cited above. “Normally, profit margin for a stockist on these pills is 8-10%, while that for a retailer is 16-20%."

MTP kit molecules mifepristone and misoprostol are price controlled under the government’s National List of Essential Medicines, bringing the total price of an MTP kit (with a single 200 milligram mifepristone tablet and four misoprostol tablets of 200 micrograms each) to about Rs370. All profit margins at every step of the supply chain will have to be produced from this maximum retail price.

For pregnant women with little awareness of the MTP Act, doctors often become the last resort for access to medical information and abortion pills. This is why women, especially those close to the seven-week deadline for a medical abortion, have to either bargain with gynecologists over prices or accept the deal they are offered.

Like for the advertising professional mentioned in the first instance. She needed a doctor because the MTP pills she had bought did not induce any bleeding, the sign of a successful abortion.

“So I went to a doctor, he showed me my baby (on an ultrasound machine). His rate was Rs8,000. But I talked to him, we discussed, and then brought it down to Rs5,000-6,000," she said.

This is the second of a three-part series. To read the first story, click here