In June 2014, Kusum (name changed), a 32-year old mother of two, found to her dismay that she was pregnant for the third time. One of her children, an infant girl, had been sick for a long time and needed constant care; a third child was a burden she wasn’t equipped to handle. But when she sought an abortion, she was turned away from a private practitioner and a civic tertiary care hospital in central Mumbai. By the time she managed to find a doctor who would perform the procedure, she was over 18 weeks pregnant – just in time to receive an abortion before the 20-week-deadline set by the Medical Termination of Pregnancy (MTP) Act, 2002.
Kusum’s daughter had been admitted to a public trust-run hospital for a long period as she suffered from asphyxia and neurological problems. “The woman was in and out of hospital nursing her sick child. She had no time to look after herself, let alone figure out that she was pregnant. By the time she came to us, she was desperate. We conducted the MTP on the grounds that she had a sick child,” says Dr Suman Bijlani, a private practitioner in Kurla.
But the family's ordeal didn’t end there. When they took the fetus for cremation – which is required by civic rules if the abortion is conducted after the second trimester of a woman’s pregnancy – officials at the crematorium interrogated Kusum’s husband and refused to cremate the fetus. The fetus was a female one, and raised their suspicions that the abortion was a case of sex selection. Kusum’s husband went back to Dr Bijlani, confused about what he was supposed to do with the fetus. Only after the doctor spoke to the administrator of the cremation ground – and explained to him that the abortion was not a case of sex selection – was the cremation allowed to take place.
In October 2014, the Ministry of Health and Family Welfare (MoHFW) proposed to increase the deadline for an abortion under the MTP Act from 20 weeks to 24 weeks, as Down’s Syndrome, heart problems, anencephaly or other fetal anomalies can be determined by then. But in Maharashtra, the consequences of this are bound to be complicated. After Census data showed a drop in the state’s child sex ratio from 913 girls between the ages of 0-6 for every 1000 boys in 2001 to 894 in 2011, second trimester abortions (abortions performed after 12 weeks of pregnancy, when the sex of the fetus can be determined on the basis of an ultrasound image), have been under scrutiny. Since the release of the Census data, activists have been lobbying for increased monitoring of ultrasound clinics and effective implementation of the Preconception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection)Act, 1994. The government cracked down on ultrasound centers that were helping parents determine the gender of the fetus, and registered around 500 cases all over the state. Wary of scrutiny from state and civic bodies, many doctors have stopped conducting second trimester abortions altogether.
In 2012, when a 26-year old woman in Beed district died after an illegal abortion when she was six months pregnant, the state government started conducting checks on abortion clinics. Clinics that hadn’t received a visit from a health officer in years had to start writing monthly reports on their work. Some doctors told me that health officers asked for details of their women patients who underwent abortions, including their contact details. Some even spoke of officers asking for prescriptions or bills for contraception pills or condoms, which are available over the counter. Simultaneously, the state Food and Drug Administration (FDA) started raiding chemists and demanded to see all paperwork related to the purchase and sale of abortion pills (which can be prescribed up to seven weeks of pregnancy). Maharashtra FDA officials claim that as a result of the raids, the use of these drugs use has gone down by 87 percent. Most chemists do not stock them anymore.
Since then, Maharashtra’s sex ratio at birth has improved. In Mumbai, the sex ratio at birth calculated each year has increased from 917 girls for every 1000 boys in 2011 to 930 girls for every thousand boys in 2013, according to records with its civic body, the Municipal Corporation of Greater Mumbai. However, these records also show a rise of more than 75 percent (from 16,977 in 2010-2011 to 30,117 in 2013-14) in the number of abortion procedures documented in the city in the last two years. “The number of abortion cases have increased since we increased surveillance. We feel this reflects the increased reporting,” says Dr Padmaja Keskar, executive health officer at the Corporation. Inspite of this, pregnant women in their second trimester find abortion services increasingly hard to access.
“Second trimester abortions can be sex selective. But these would be about 10 to 15 percent of the cases,” says Dr Nozer Sheriar, secretary general, Federation of Obstetric and Gynecological Societies of India (FOGSI). “Because of these kinds of cases, the pressure on the health officers is to focus on sex selective abortion. All second trimester abortions are stigmatized as a result.”
Under the MTP Act, a doctor may terminate a pregnancy on the following grounds: if the pregnancy is likely to cause physical or mental harm to the mother; if there is a fetal abnormality or the likelihood thereof (if mother is an alcoholic or a drug addict, for instance); if the pregnant woman is a rape survivor, or if a pregnancy is the result of contraception failure in a married couple (this clause does not take into account unmarried women). In the case of a second trimester abortion, two doctors need to consult on the subject and sign the requisite documents.
While the pregnant woman's consent is a must, the power to decide on an abortion rests with the doctor. As a result, the right to refuse an abortion also rests with the doctor. Refusing to provide a service would have seemed like a clear ethical violation in the past. But now, doctors in Mumbai blatantly violate the code, citing self-preservation. Many say that while they pity the patient, they have to look out for themselves. Of the 24 doctors (gynecologists in public hospitals and private practioners in Mumbai, Thane and Sindhudurg) I spoke to, at least half of them said that they had refused to provide a second trimester abortion to patients for various reasons.
“If a woman is not my regular client, I feel it’s better not to do [a second trimester abortion] at all. We do not know if the patient is genuine or not. If someone comes and tells us, ‘I have enough children and I did not realize I was pregnant,’ how do I believe her? I know it may not be the right thing to do, but we do it for our mental peace,” says Dr Sudhir Naik, who runs a maternity and pediatric nursing home in Goregaon east. “Besides, why should we inadvertently help someone with sex selection? The sex ratio is declining,” he adds.
Morality crops up very often when speaking to doctors about MTP. Many of the ones I spoke to have turned to assisted reproduction – a lucrative market – and have started describing themselves using that American label: “pro-life”. A gynecologist on Mira Road, a suburb just outside Mumbai limits, was vehement about her stand on abortion and said, “You [can] ask me about anything, but not abortion. It is against my religion and my values. I am pro-life.” Another gynecologist said she was squeamish about conducting second trimester abortions, as the fetus is well-formed by then. Health activists are concerned that ‘morality’ here is being used by doctors as a shield; a report by the Centre for Enquiry into Health and Allied Themes (CEHAT) raises the worry that the government's concern over sex-selective abortion has “given providers the opportunity to project themselves as morally upright, at a time when the medical profession has been receiving a lot of flak for being commercially minded and lacking concern for people's wellbeing.”
Many women in Mumbai are now having to shunt from doctor to doctor, losing precious time in the process of finding someone willing to perform an abortion. Women living on the outskirts of Mumbai have to travel to the few centers in the city that are conducting second trimester abortions because they cannot get abortions nearby, even for cases in which abortion is allowed. Dr Atul Ganatra, who is chairperson for MTP at the Federation of Obstetric and Gynaecological Societies of India and practices in Mulund, says he has had patients from neighboring Thane district coming in for abortions of fetuses with detected anomalies. “Doctors are getting into trouble with government officials so often. I have been getting about 2-3 emails from gynecologists in Maharashtra every week with respect to harassment from health officers. Some are not given licenses. Some are facing trouble in specific cases of abortion, where police may be involved,” he says.
In 2013, Samyak, a Pune-based non-profit working for women’s rights, conducted a qualitative study on service providers in Western Maharashtra. It found that many doctors do not conduct second trimester abortions for fear of being punished by the government, or to avoid having to be diligent about maintaining their paperwork.
Doctors who run nursing homes (where a second trimester abortion can cost between Rs 25,000 and Rs 30,000) often send their patients to corporate hospitals (where it can cost between Rs 65,000 and Rs 70,000) on the pretext that government officials are less likely to harass a corporate entity. However, many corporate-run hospitals – such as Lilavati Hospital and Holy Family Hospital in Bandra, and Saifee Hospital on Charni Road – are run by religious trusts, and refuse abortions on religious grounds. Hospitals such as Cumballa Hill Hospital & Heart Insitute on Grant Road and Hinduja Hospital in Mahim are among a few that have chosen not to do any obstetric care (services related to pregnancy, abortion, childbirth and the postpartum period), but only provide other gynecological services such as fibroid surgeries.
There are 179 centers registered to provide second trimester abortions in Mumbai, but very few of them provide them easily. The shortage of doctors willing to perform them has also increased the cost of this procedure, which remains a deterrent for many women, especially college students and women from economically weak backgrounds. That leaves public hospitals. Doctors from public hospitals say they’ve attended to patients from as far off as Ambernath and Raigad districts for second trimester abortions. However, like in Kusum’s case, many of these patients were turned away from public hospitals on the suspicion that theirs was a case of sex selection.
“We do not encourage second trimester abortions. There is a chance of sex determination. If the first child of the woman is male, then we do not hesitate. If her first child is a girl, we do not allow it. Or else we do it along with the tubal ligation [permanent sterilization] procedure. Then we know it is a genuine case,” says a senior doctor at a tertiary-level public hospital. (According to Mumbai Corporation figures, for the 30,117 abortion procedures that were performed between April 2013 and March 2014, around 21 percent – 6,207 – of them were accompanied by sterilization procedures.) While the screening is done by social workers at public hospitals, some private doctors admit that they screen patients too.
The 2010 guidelines issued by the Ministry of Health and Family Welfare for doctors say that a woman should not be refused abortion, as she could resort to undergoing it illegally or using unsafe methods. While the counselling process for women who opt for MTP should involve a discussion on contraception, the guidelines clearly state that an abortion should be provided, irrespective of the woman's decision to use contraception.
The guidelines also state that in the case of second trimester abortion, the provider should ascertain that abortion is not sought following prenatal sex determination. It however, does not explain how a doctor conducting the abortion is expected to verify it.
Screening and monitoring of patients began in earnest after the 2011 Census, as the Maharashtra government started monitoring women with one or more girl children. This procedure has a basis in trend analysis, on which a study was published in Lancet that year (one of the authors is Jayant Banthia, who was the state’s principal secretary, Health and Family Welfare, at the time). The study showed that the likelihood of selective abortion of a female fetus increased during the second pregnancy if the mother’s first-born was a girl.
But in the dash from one doctor to another, many women who end up missing the deadline of 20 weeks are not able to abort the pregnancy. Dr Vijaylaxmi Chindak, a Sindhudurg-based gynecologist, tells me about a woman who had two boys and wanted to abort her third pregnancy. “She was poor and was refused [an abortion] by a private doctor and a public hospital in Mumbai. By the time she came to me, she had crossed 20 weeks,” she says. “She must be six-seven months pregnant now.”
At a Mumbai clinic
To understand what the process of seeking an abortion involves, I visited the Family Planning Association of India clinic in Tilak Nagar.
While sitting in the clinic with Dr Shruti Shah and Dr Jyaneshwari Phadke, I saw a few women there who had very young children, some only infants, and had conceived because of the popular misconception that they would not get pregnant if they were lactating. What was evident was a clear lack of knowledge about contraception. A 22-year old woman who had undergone an abortion at the clinicin October had become pregnant yet again. She had taken contraceptive pills only for a month, and hadn’t collected a second lot. She wanted to undergo another abortion. “We had a woman who had 11 children and had conducted eight abortions after that. She has undergone 19 pregnancies. We need a policy like China's,” Dr Phadke grumbled.
Later, a 22-year-old mother of two boys kept insisting on a sterilization surgery, while the doctors told her she was too young to take such a permanent step. The responsibility of contraception seems to fall squarely on women, and it is telling that in this woman’s case, she was willing to undergo a permanent procedure.
The duo were surprised when a 38-year old woman came in seeking infertility treatment. She had two daughters aged 15 and 17. “I underwent an abortion five years back. It was a girl. Khali karaya Azamgarh mein (I had an abortion in Azamgarh),” the woman said said matter-of-factly.
Dr Phadke looked visibly disturbed. “Why should we provide services in such cases? How do we know she won't abort after sex determination again?” she said.
Team Anti-Sex Selection vs Team Right to Abortion
This confusion on how to reconcile the two issues of sex selection and a woman’s right to abortion has seeped into public policy too. How do we ensure there is no sex selection while the right to abortion is upheld? There are no clear solutions to this problem. Activists fighting on both sides do not see eye to eye.
While there are concerns that the monitoring of women with girl children in Maharashtra invades women’s privacy, activists working against sex determination feel that it is a necessary evil. “Community monitoring should not be done away with. Abortions being denied is collateral damage,” says Vibhuti Patel of the Forum Against Sex Selection, a network of organizations and individuals that work on the subject.
Varsha Deshpande, the founder of Lek Ladki Abhiyaan, which has conducted many sting operations against errant doctors in the past, says that the doctors' lobby is spreading rumors about the extent of the problem of women finding it difficult to terminate second trimester pregnancies. “These cases are too few. We cannot risk the lives of six lakh girls who are not born as a result for these few cases. Monitoring has to be constant,” she says. Deshpande also believes abortion is a health right, and not a fundamental one. “When the doctor feels its important for the patient, then we should use abortion. Once someone has sex, responsibility comes in. Sex is not just to be enjoyed. There are responsibilities, rights and duties attached to it,” she says.
Anand Pawar from Samyak, a Pune-based non-profit that works on women’s rights, says there is a lot of mistrust between those who fight against sex selection and those who fight for abortion rights – the two groups have to be dealt with carefully. “There is a whole lot of confusion created by civil society and government machinery. Many doctors speak of ‘brunhatya’ or ‘killing of fetus’. Many government documents still use such language. We are trying to meet and work together.” A coalition of organizations under the umbrella of the Pratigya Campaign has been formed with the intent to address the two issues with equal regard for their importance to the lives of women and girls.
Meanwhile, there are those who see a larger agenda to the proposed MTP amendment to extend the deadline for second trimester abortions. Nirja Bhatnagar, regional manager of ActionAid India, says the proposed amendment should be seen in the changed political context. “The MTP Act is being changed because the state wants to control women’s sexuality. And if she is healthy, why can't she have three or four children? This is hegemonic politics at work,” she says.
While there has been no large-scale research done on second trimester abortions yet, some NGOs are trying to build this data. One example of this is a study conducted by Shireen Jeejeebhoy from Population Council on factors associated with second trimester abortion in the rural populations of Maharashtra and Rajasthan. The study shows that exclusion from abortion-related decision making, distance from an abortion center and failed prior attempts to abort are strongly associated with second trimester abortions.
Dr Suchitra Dalvie, coordinator for Asia Safe Abortion Partnership, says that the Preconception and Prenatal Diagnostic Techniques Act and the MTP Act have to be implemented separately. “There is no data to prove that by increasing the sex ratio of women, gender discrimination in society reduces. Girls are not given better status. Who is seeing whether these girls are being fed, immunized and educated? What kind of society are we bringing these girls into? Sex selection is also happening post birth,” she says. Padma Deosthali from CEHAT agrees. “One has to look at the declining sex ratio as gender discrimination. We need long-term strategies, not shortcuts like these. Can you imagine what a woman who needs to undergo an abortion must be going through? They are the most vulnerable people,” says Deosthali.
But there is one clear agreement across the board – that doctors should not shirk from their responsibilities.
“I have never been harassed by the authorities,” says Dr Sachin Dalal, who runs a polyclinic in Bhandup. “One needs to be careful with paperwork and one should follow the law. I do not understand why others refuse so many abortions. Imagine all those unwanted babies. We need to make changes in the system so that the women do not have to run around here and there for an abortion.”.
Doctors who are harassed by government officials merely for doing their job should be protected by civil society, says Dr Amar Jesani, who edits the Indian Journal of Medical Ethics. “But, it is not the doctor's responsibility to find out whether an abortion is a sex-selective one. These are just excuses to deny rights to women. Will they stop practicing if the Clinical Establishment Act [which aims to regulate nursing homes and clinics] is enforced in the state? Society has a right to monitor them,” he says. “They have to be accountable and respect the rights of women.”
Menaka Rao is a freelance journalist based in Mumbai.