Safe Abortions in an Unsafe Pandemic?
In Eliza Hittman’s film Never Rarely Sometimes Always, seventeen-year-old Autumn (Sidney Flanigan) is pregnant and travels far to get an abortion. Autumn is the embodiment of fear wrapped in vulnerability wrapped in the terrible fragility of existing as a seventeen-year-old girl in a patriarchal world. Her face might give you the impression of a girl constantly at the edge of a breakdown. When she finds out she is pregnant, she stands facing a mirror and punches her belly. When she visits a doctor to seek an abortion, the receptionist shows her a video of a foetus’ journey and warns her to reconsider. When she lays still as a doctor applies ultrasound gel on her belly, the doctor makes her hear the foetal heartbeat and tells her that it is the most magical sound she would hear. Watching Autumn’s journey through the bureaucratic hurdles of seeking an abortion in the United States is likely to be nightmarish for young women all over the world. When her cousin Skylar (Talia Rider) says to her, “I wanna make sure you’re safe”, you wonder about the gap between being safe and feeling safe.
That’s when there isn’t a lockdown on.
When there is, things can get life threatening. Dr Imaan Api, a gynaecologist who works at The Calcutta Medical Research Institute says: “There was a young single woman who came to us who was pregnant and could not terminate it on time. She then took an MTP (Medical Termination of Pregnancy) pill and ended up with severe blood loss, haemorrhagic shock, and the delivery of a dead baby.” Stories like these in times of a national lockdown are not hard to trace.
While conversations surrounding sex and sexual freedom are starting to become normal amongst a certain demographic of young women, the complicated dynamics of getting an abortion in India are scarcely touched upon. In a survey conducted by the NGO Tarshi (Talking About Reproductive And Sexual Health in India) in Delhi, it was found that only 20% of a total of 769 women above the age of 18 were aware of the abortion law in India.
In 1971, when the MTP (Medical Termination of Pregnancy) Act was passed in India, it was seen as a socially progressive law. But the makers of the law didn’t exactly have women’s autonomy, agency and control over their own bodies in mind when they made it. The Shanti Lal Shah Committee, which was set up by the Union Government to find out why so many women were dying in India, spent three years travelling all over the country looking for an answer. They later found that women were dying because they were having unwanted or unplanned pregnancies and there were no safe ways to terminate them, and thus the law came into being.
“It is not a rights-based law,” says Dr Suchitra Dalvie, a coordinator at Asia Safe Abortion Partnership and one of the leading campaigners of safe abortion in India. “It was proposed to reduce the very high maternal mortality rate in women due to septic abortions”.
The law allows abortion for only up to a period of 20 weeks. Besides, since abortion is a time-sensitive issue, being able to seek it on time is of utmost importance, lockdown or not. The lockdown, however, made it tenfold difficult for women to seek medical termination of an unwanted pregnancy. The suddenness with which the lockdown was declared wasn’t exactly good news for young women who wanted to get an abortion. Little attention was paid to their access to safe abortion services, which meant that many women would be forced to seek either clandestine abortion services or to continue their pregnancy.
“They may feel that it is something like a crime and you need to really go in secret to somebody who’s under the radar which is why they go to unqualified, untrained people like Daais (midwives) or they take home remedies and end up in trouble,” says Dr Dalvie. She says that the maternal mortality rate caused by unsafe abortions in districts in Uttar Pradesh and Jharkhand may be as high as 50 per cent.
Our social attitudes tend to ask: What’s wrong with these women? That’s not precisely fair. These women don’t have a death wish. A more productive question would be: Why are women not comfortable with approaching the system? Why do they choose to go outside the system? What is it about the system that makes it difficult to approach if not hostile?
While gynaecologists in India are obligated to provide such services under lawful conditions, most of them are easily alarmed upon hearing the A-word. This may have moralistic grounds, but it has to do partly with the prevalence of campaigns opposed to sex-selective abortion in India, unwittingly linking medical termination of pregnancy to gender discrimination.
“This conversation needs to happen in the context of gender discrimination and not in the context of abortion as it doubles the stigma around abortion without addressing the real issue which is why don’t people want to have girls,” says Dr Dalvie.
It is estimated that 15.6 million abortions take place in India each year and a bulk of them are self-performed. Picture this: a guilt-ridden woman, terribly scared and alone, has locked herself in a room, and is ready to surrender her health to the hands of an old woman someone told her about or to Dr Google and do just about anything to get herself out of the clutches of the life-sized monster that is a pregnancy. Her mind compulsively backtracks to details of her sexual encounters, as she nervously takes into account the options that lie ahead, the resources she must arrange, the people she must lie to, and the hope she must muster to preserve her sanity. Now imagine inhabiting this state in a lockdown.
When the lockdown was set in motion, the first instinct of young women who did not know where to go to or whom to talk to was to self-induce a termination of pregnancy. Historically, even before MTP became legal, women have always sought to end an unwanted pregnancy by inserting sticks in their uterus or throwing themselves down the stairs, or by consuming poison. Jasmine George, the founder of Hidden Pockets—an organization that is one of the leading names in providing sexual and reproductive healthcare to young women—told me that many of her clients, in a haze of panic, consumed allegedly pregnancy-terminating foods like papaya upon skipping their period, without knowing if they were pregnant.
George’s platform is a torchbearer in “standardising care and improving standards” by “hand-holding” women through their abortion.
“We are very clear about ensuring that care is the first language we speak,” says George, further adding that the platform tries to be there for a proper, holistic, and care-filled health journey for young women. This is manifest in their work during the pandemic: Besides directly interfering to ensure that abortion was seen as an essential service, the collective also catered to Tier 2 and Tier 1 towns including Chattisgarh. Orissa, Madhya Pradesh and Nagaland to ensure that young women had access to clinics. The sexual and reproductive health advocate who is also a lawyer, thinks that it is high time MTP laws reflect the reality of women. This means that rights have to be given in a “basket of choices” if they are to hold significance.
George started her platform so that one day, young women who find themselves at the crossroads of unwanted pregnancy would feel less alone. “Young women in this position are scared that their life will be over,” she says. “In India, even if you are married, nobody talks to you about whether it's okay for you to take an ipill, or to not take it, or if your body is ready to take an ipill, or whether you could have an allergic reaction to a condom. Our knowledge is not even zero, it’s in the negative range. Therefore the paranoia young women feel is legitimate.”
At Hidden Pockets, she places special importance on counselling. The relationship that the staff have with their clients is that of a “friend”, where young women who are otherwise used to hiding their pain and who wait for their pain to become extreme before approaching a doctor have a friend to share their most private anxieties with; a friend to tell them what the hell is happening with their body.
Within the spectrum of abortions that women seek in India, about 81 per cent are by women using self-medication pills. As lockdown began and footfalls in pharmacy shops reduced as supply was cut short, it became less possible for young women who live with their families to order pills online. Being safe in theory, medical abortion pills require medical guidance. “You can’t advise people about abortion online. It needs to be done in-person to know whether it is low risk or high risk,” says Dr Nupur Gupta, a gynaecologist with Fortis Memorial Research Institute in Delhi, who was only treating a handful of emergency patients since patients were not showing up at her clinic.
“What you consume has long-term effects on your body,” says Dr Gupta, who points towards the need for contraceptive counselling. “Sometimes neither a male partner nor female partner knows what to do due to limited knowledge”.
The second trimester in pregnancy is tougher than the first trimester. The facilities that provide it in the country are few. It is more complicated, leads to more blood loss, and in India needs the signature of two gynaecologists. The lockdown only worsened this; foetuses which were deformed were diagnosed late, as women could not seek medical help on time to get a sonography done. When pregnancy is beyond its gestational limit, doctors cannot help.
When it comes to the public health sector, the most common excuse doctors have for not keeping medical abortion pills is that they’ll get stolen and misused. “The ‘misuse’ here implies a moralistic bias; you want to punish someone who seeks easy access to medical termination of pregnancy by calling it misuse,” says Dr Dalvie. The stigma is not about abortion as much as about the act of sex which led to that pregnancy. The assumption is always that young unmarried girls will be seeking the ‘morning-after pill’ as it is called, but the reality is that the vast majority of abortions in the country, Dr Dalvie says, are sought by married women seeking to control their family size. (Note: Public health hospitals remain infamous for forcing unsuspecting vulnerable women to be sterilized).
As there were no clear guidelines for women seeking MTP, MTP hotlines in India were flooded with women calling to ask about whether it would be possible to get an abortion in the lockdown.
“We had very few women approach us for abortions during the pandemic,” says Dr Shwetangi Shinde, a medical intern at a hospital in Mumbai. “Around 10-15 women visited each of our units per week pre-pandemic, but we saw only about 1 woman every 10 days during the lockdown”. Dr Shinde, in her time at the hospital, has been witness to a range of abuse and exploitation: A sex worker made to clean floors when wanting an abortion. A patient who upon visiting a “shady” doctor got an IUD inserted in her while she was still pregnant. The foetus was then removed, after bleeding for days, followed by a hysterectomy. This was a 28-year-old woman who had decided to end her 8th pregnancy. Scared and without support, she whispered to Dr Shinde, “The future does not look very bright to me”.
Lack of mobility prevents women from reaching out. Not only were young women indefinitely stuck in their homes, they were surveilled and questioned by the police upon stepping out. MTP was only included in the essential services by the May 24, 2020, and needless to say, women were hesitant to reveal the true cause of travel to the police. When one of Dr Shinde’s patients was interrogated by the police and told them about her pregnancy, the police got suspicious as she didn’t have an obvious bump and beat her partner up for breaking lockdown norms.
When doctors were inaccessible, young women went to the internet to help themselves and tried to self-abort.
Artwork by Bruvee Manek
In the lockdown, without means for transport, pregnant women have had to walk for miles to reach a hospital.
Artwork by Bruvee Manek
During the peak of the lockdown, when the streets were bereft of public transport, the burden of arranging means to travel fell on people, many of whom do not own a vehicle. “One of my pregnant patients had to walk for 10 kilometres to reach my clinic”, says Dr Shubhada Gupta, a gynaecologist from Bhandup. Public toilets being shut only added a layer of difficulty for women whose condition necessitated use.
Among the few rickshaw drivers who were functional, a number of them charged exorbitant sums from their customers. V. S. Chandrashekhar, the CEO of the Foundation for Reproductive Health Services (FRHS), had to send ambulances—which are not very cheap—to clients’ houses so that they could reach clinics without law enforcement putting barriers in their way. FRHS kept their lines open and asked clients to call them directly so that they would talk to the police if required.
Not having the option to go out led to an obvious surge in ‘online consultations’. Dr Minakshi Tomar, a gynaecologist from Nahur, was quick to set up her service online. She put an online status update and WhatsApped each of her patients to inform them that she was providing free online consultation and would be “very much available”. Online consultation, though, has its limits as not everyone has access to an online device or knows how to make an online payment. Dr Kanchan Patil, a gynaecologist from Nallasopara who has been dealing with patients for over 40 years, hated teleconsultation. “It was largely confusing as most of the communication happened through WhatsApp and I didn’t want to take responsibility if something went wrong.”
While countries like the UK offered women a facility known as ‘pills by post’, where MTP pills were delivered to patients by mail, countries like New Zealand and France okayed Telemedicine as an alternative where doctors could prescribe pills to patients via phone. The Indian government came up with Telemedicine guidelines in May, which had no mention of whether abortion pills would fall under it. I asked Dr Dalvie how prescribing pills on phone being illegal impacted her practice: “The hardest thing for me was knowing that there are women who need help but that I could not offer them any.”
As more and more rooms in hospitals were turned into Covid wards, resources needed to treat non-Covid patients took a hit. For Dr Tanaya Narendra, a gynaecologist from Uttar Pradesh and an award-winning sex educator on Instagram, “the lack of supply was a huge issue and there was a genuine crunch in resources”. When the lockdown happened, the hospital she works at had run out of gloves and masks. According to her, the hospital has an industrial consumption of masks and the change in price from Rs. 3 per mask to Rs. 40 per mask really pinched them in the pocket. It would take ages to get those masks shipped. So they reused their masks (which is not a good idea, she adds). They had no PPE (Personal Protective Equipment). This led to doctors reusing their OP gowns every day by putting them out in the sun so that they get sterilized. Dr Narendra, who goes by @dr_cuterus on Instagram, does regular ‘myth-busting’ about women’s sexual health to curb the misinformation that shows up from time to time. The more anxiety, the more rumours, she tells me.
Globally, doctors knew that the best precautionary measure for treating any patient was to think of them as being Covid positive. But some gynaecologists in India went one step ahead and asked potential patients to get tested if they wanted to visit them. “A Covid test is not always easily possible to do and requires at least 24 hours to get you results, and you cannot ask someone to get tested in an emergency. It is unethical,” says Dr Patil, whose credo to remain safe and alive for the entirety of pandemic has been: Trust in God. The hospital in Nallasopara she works at decided to cut down its patients by only taking in previous patients, out of fear of being overburdened. All of this would go on to make women doubly scared. Weighing the fear of getting pregnant against the fear of having contracted Covid, many shied away from taking the Covid test. Getting tested positive, above all, would foreclose the possibility of getting an MTP for at least two weeks.
Hospitals didn’t stop at refusing young women abortion because they were not Covid-tested. They denied them services left and right, by turning the pandemic into a seemingly foolproof reason for not treating. “Nahin hoga, Pandemic ke vajah se band hai,” (Not possible. Not during the pandemic) went the common refrain, according to Dr Riti Sanghavi, a medical intern at a hospital in Nagpada. The focus instead remained on pregnant women and their delivery. MTP became dispensable. Because of this neglect, MTP could easily turn into a surgical abortion. The flip side to women not getting an abortion was that for some women who were unsure about their pregnancy, the limited access to readily available abortion facilities prompted them to make a hasty decision.
Remember reading statistics about the rising rates in the number of domestic violence and child marriage cases brought forth by the lockdown?
If one were to go by them, one can make a case for a larger need in the ability to access safe MTP services now than ever before. When migrant workers lost their jobs and had to move back to their native places, their cohabitation habits changed.“The sexual abuse in homes increased because men had no work and their wives would become an easy target to let their frustration out on,” explains Dr Arun Gadre, an author and gynaecologist from Pune. Linking child marriages to the growing pandemic isn’t a tough call. The pandemic brought into light larger questions like those of death, safety and security. When our notions of security with respect to young girls are hinged upon protecting their ‘honour’ through their virginity, worrying parents think it fit to marry off their daughters so that she is ‘protected’.
The issue of access to MTP services is ultimately an issue of what the people in power think of the women desiring medical termination. Our stereotypes maintain that women are not supposed to be sexually active. Wanting MTP, therefore, cannot possibly mean anything to us. ‘Unmarried’ women don’t get pregnant. And if they do, it must be a God-given punishment to make them suffer. This is the lie we sell ourselves when we refuse women basic healthcare. Because of our difficult relationship with pleasure, the idea that a young woman could have a sex life and claim ownership over her own body eludes the narrow confines of our expectation from India’s Daughters. After all, Bharat Mata is for everyone to lay claim over, except her own self.