By Kamayani Bali-Mahabal, Women Feature Service
Mumbai: The recent proposal by the Ministry of Health and Family Welfare (MOHFW) to amend the Medical Termination of Pregnancy (MTP) Act of 1971 has received a mixed response. While women activists and many others welcome the move to increase the period for an MTP from 20 weeks to more than 24, the proposal to permit health care providers, such as homeopaths and vaids (traditional medical practitioners), to conduct the procedure has triggered a debate – unmet need v/s safety, with unsafe abortions accounting for eight per cent of all maternal deaths in India.
The MTP Act 1971 was intended to reduce the incidence of illegal and unsafe abortion. Yet, women in India continue to obtain abortions outside of registered settings and/or from uncertified or illegal practitioners. It is estimated that over 5.5 million of the 6.5 million abortions taking place annually are conducted by uncertified providers or in unregistered facilities.
As per the National Alliance on Maternal Health and Human Rights (NAMHHR), which has 37 members from 14 states in India, maternal deaths and morbidities can be addressed by expanding the base for safe abortions, keeping in mind medical advancements. Welcoming the proposed amendments, former Right to Health Rapporteur, Advocate Anand Grover, observes that task shifting from physicians to other health professionals or task sharing with these professionals represents a significant departure from traditional delivery models that depend on specialist providers and can make a major contribution to expanding access to reproductive health services, especially in underserved areas and for poorly served groups. “Experiences from both low- and high-income countries suggest that task shifting or sharing has been successful in both expanding services and improving outcomes for patients, without compromising patient safety and satisfaction,” he says, adding that many developing countries, including Cambodia, Ethiopia, Nepal and Vietnam, have reviewed their abortion guidelines to allow trained non-physicians – typically, nurse-midwives and physician assistants – to perform abortions. Studies in India and Nepal have revealed that healthcare professionals, other than physicians and/or nurses, provide medical abortion (MA) as safely and effectively as physicians do.
Looking at the issue from a health and human rights perspective, Jashodhara Dasgupta, Convenor, NAMHHR, says, “One of the major amendments in the Act calls for expanding the base for medical termination of pregnancy by including mid-level providers in conducting the procedure, particularly during the second trimester, and certification for allowing abortion by one provider as against two, as is the case right now. In the backdrop of a 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 – often acts as a barrier for women who want to go in for the procedure. The issue is more critical in the rural areas where there is an acute scarcity of gynaecologists even at the Community Health Centres (CHCs). The system, therefore, forces women to go in for unsafe procedures.”
Dasgupta points out that the recent national level Facility Survey report (IIPS, 2005) highlights that only 15 per cent of the Primary Health Centres (PHCs) in the country have at least one doctor trained in MTP. This implies that 2.24 lakh of the rural population has access to only one MTP trained doctor. The Facility Survey 2003 reveals that while 60 per cent of PHCs are equipped with MTP equipment, only six per cent offer safe abortion services. One of the key reasons for this is the non-availability of trained providers. Even if one trained doctor is available at all PHCs 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.
Dr Sebanti Ghosh of the Association for Social and Health Advancement (ASHA), West Bengal, also reiterates the need for providing MTP services within the PHC system. Government of India guidelines, including the latest Maternal and Newborn Health (MNH) Toolkit 2013, clearly state that Level 2 facilities, like 24×7 PHCs and non-First Referral Units (FRU) CHCs should provide safe abortion services and necessary post-abortion contraceptive counselling. “Usually, first trimester abortion should be performed at Level 2 facilities with the preferred method being the manual vacuum aspiration (MVA) technique. Medical officers need to be trained on first trimester abortion methods, especially MVA,” she says. The Level 3 facilities, like FRUs at the CHC and Sub-Divisional and District hospitals, should provide comprehensive – both first and second trimester – abortion services. There is a need to strengthen referral linkages in case of abortion complication, Ghosh adds.
Associated with Jan Swasthya Abhiyan, a national platform of health rights organisations, health analyst Ravi Duggal cautions, “Even MBBS doctors without proper training are incapable of doing abortions.” Little is known about failure rates arising from MVAs in India even among certified providers. A Federation of Obstetric & Gynecological Societies of India (FOGSI) study of 2007 found that abortion failures and other complications were experienced by 2.9 per cent of women who underwent abortion – 2.1 per cent among those with gestation ages of less than eight weeks and 4.5 per cent among those with gestation ages of over eight weeks. So the issue is not of the provider’s level of medical skill but how well s/he is trained to do the procedure. “The centerpiece of the debate should be proper training and then there is no reason why an Auxiliary Nurse Midwife (ANM) cannot do first trimester abortions,” he adds.
What Duggal is wondering is “why is the Indian Medical Association opposing the amendments?” He feels the allopaths should first give evidence that they can regulate themselves and become ethical in medical practice. “If they are so concerned that this should remain an allopathic monopoly let them first demonstrate their willingness to go and work in public health institutions – do compulsory service in PHCs and rural hospitals for three to five years. If the latter had been done we would not have to bring in non-allopaths to be trained as abortion providers,” he argues.
Manisha Gupte of Medico Friends Circle, a voluntary group of health activists, asserts, “There is a need to de-link gender and disability discrimination from the right to safe abortion. There should be no tracking of pregnant women and abortions for any purpose.”
She advises, “Backup and referral services [for example, blood bank, higher level medical services and facilities] required for each of the providers should be specified in the Act, to minimise risks and ensure safety. These requirements should be specifically included in the form through which the registration will be granted, and the certificate of registration should mandatorily be displayed at the service centre. Abortion services that can be provided with quality and safety at the sub-centre level should be compulsorily made available in all sub-centres in the public health system. These sub-centres should be equipped to provide the backup and referral services that will also be required by paramedic and non-MBBS providers.”
In a statement, Medico Friends Circle states: ‘In cases of illegal abortions, there is a provision in Sections 310-315 of the Indian Penal Code to criminalise the woman. The MTP Act should include a clause to disallow this. … [And] despite the Act clearly stating that only the consent of the woman is necessary, it is a standard practice to obtain consent of the husband/partner/parents. This violates a woman’s right to abortion and the confidentiality clause. A new clause that specifically states that consent of others is not required should be inserted.’
Will an amended MTP Act enable women access to safer abortions? Only time will tell.