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Medical Termination of Pregnancy

By Advocate Meenu Padha and Varushi Yadav 

Introduction

It would not be wrong to argue that in India, the concept of human rights was first introduced and systematically institutionalised in 1950 when our country’s Constitution came into force. Many governmental programmes and methods have been created to supplement the rising acknowledgement of an individual’s rights, and the human rights movement has witnessed significant progress and success.

In India, the issue of reproductive rights remains uncertain. While the importance of both men and women’s rights to choose and control their own reproductive functions has grown in prominence, the concept’s introduction in India is particularly difficult due to the country’s complex social structures, where procreation is frequently seen as a social expectation and individual rights are often overlooked. Reproductive rights, in a broader sense, have received greater attention in recent years. This is due, in part, to the unwavering efforts of civil society organisations, who have emphasised the importance of international treaties in the Indian context.

Experts have pointed out that reproductive rights are an intrinsic aspect of human rights in general, as well as our Constitution on a national level, and that India owes them to all its women and those who identify as such. Reproductive rights and a larger human rights framework are mutually interdependent. Reproductive rights receive their meaning and force from long-recognized human rights, just as human rights cannot be realised without championing women’s reproductive rights. However, how the two are combined in practice is unclear. Indeed, explaining to an Indian audience that reproductive rights pertain to everyone, regardless of age or marital status, is a tough notion to grasp. It’s no surprise, then, that reproductive rights have yet to be fully established, despite the fact that they are an inalienable component of every human being.

Miserable Condition That We Need To Be Aware Of

In India, one woman dies every 15 minutes during pregnancy and childbirth due to lack of healthcare. Despite the fact that India legalised abortion over five decades ago, access is highly limited, and one woman in India is believed to die every three hours as a result of unsafe abortion. Despite national legislation prohibiting the marriage of girls under the age of 18, India continues to have the highest number of child weddings; and despite regulations and initiatives ensuring women’s maternal healthcare, India is responsible for 20% of all maternal deaths worldwide. Several states have established coercive population policies that bar families with more than two children from assistance programmes, government jobs, political engagement, and access to education and health care – all without ensuring that couples have access to a full range of contraceptive treatments.

Furthermore, Indian women face one of the world’s highest rates of HIV/AIDS infection and discrimination if infected, as well as forced abortions of female foetuses, trafficking for forced prostitution, custodial rape in government institutions, workplace sexual harassment, and harmful cultural practices that seriously undermine reproductive health. As numerous national and international stakeholders battle to give meaning to essential ideas such as women empowerment, rights, and choice, the right to reproductive health, including abortion, takes on special significance in the Indian context. A woman, for example, should have the freedom to choose whether or not she wants to marry, who she wants to marry, whether or not she wants to have children, how many children she wants to have, and the spacing between them. This is significant because, while both the male and female contribute to procreation, it is the female who is biologically responsible for ensuring the baby’ complete growth.

In the past, India’s reproductive health legislation and policies have failed to embrace a rights-based approach. Simply put, based on the various definitions of reproductive rights, they can be said to include some or all of the following rights: the right to safe and legal abortion; the right to control one’s reproductive functions; the right to access in order to make reproductive choices free of coercion, discrimination, and violence; and the right to access education about contraception and sexually transmitted diseases. The need for us to recognise and address these as rights has become even more apparent in the midst of the pandemic when women have been left to suffer as a result of massive changes in family and social dynamics, disruption in peer support, and a lack of health facilities – because they have not been informed and empowered to demand what is due to them.

According to a new survey issued, over 139 million women and girls in India currently use contemporary contraception techniques. The progress made in family planning over the last eight years is detailed in a study issued by FP2020, a global collaboration that supports the reproductive rights of women and girls.

Reproductive Laws And Rights One Should Be Aware Of

In 2021, the Medical Termination of Pregnancy Amendment Act 2021 was passed with certain amendments in the MTP Act including all women being allowed to seek safe abortion services on grounds of contraceptive failure, increase in gestation limit to 24 weeks for special categories of women, and opinion of one provider required up to 20 weeks of gestation. Abortion can be performed until 24 weeks of pregnancy after the MTP Amendment Act 2021 has come in force by notification in Gazette from 24th September 2021. The government’s public national health insurance funds, Ayushman Bharat and Employees’ State Insurance cover abortion completely, with the package rate for surgical abortion set at Rs 15,500 which includes consultation, therapy, hospital stays, medication, Ultrasonography, and any follow-up treatments. The package rate for medical abortion is Rs1,500 which includes consultation and Ultrasonography. 

Despite the fact that safe abortions are a state-mandated service, only around a quarter of abortions are performed at public health institutions. The majority of public health services in rural areas do not provide safe abortion services due to a lack of resources and equipment. Despite the fact that this law allows women to get safe abortions under specific circumstances, there are still a number of obstacles to overcome.

Covid 19 Impacts On Contraception And Safe Abortion Services

During COVID-19, the Ministry of Health and Family Welfare (MoHFW) deemed contraception and safe abortion services to be essential health care. COVID-19, on the other hand, has increased the existing difficulties in obtaining these services. Abortion is a health care service that saves lives and protects the health and well-being of women and girls. Understanding how organizations have adapted their safe abortion care programmes to maintain service delivery while seeking to protect their clients, staff and communities from contracting COVID-19, is vital, Covid-19 has wreaked havoc on many aspects of our lives across the globe, reproductive health and family planning are no exception. Over the last 18 months, access to women’s health care services, including contraception, family planning and abortion, has been severely disrupted. As a result, an estimated two million women have experienced unwanted pregnancies. Furthermore, a survey conducted by the World Health Organization suggested a 68% disruption to family planning and contraceptive services across 105 countries.

Although still reeling from the effects of the sudden pandemic onset, the health system over the last year attempted to adapt to meet the growing need for effective women’s care and foster preparedness. One shining example of this was the sudden rise in the provision and adoption of online teleconsultations and digital resources. Availability and accessibility posed two critical components that needed strengthening in care delivery. With the advent of digitalization in the country, spearheaded by the government’s flagship Digital India initiative, we have advanced every day, reaching women from more remote and far-flung corners of rural India with digital platforms. Due to a decline in in-clinic consults, travel restrictions, and overburdened infrastructure and practitioners, Covid provided a significant obstacle to getting such treatment, adding to existing limits in women’s health — social stigma, misinformation, lack of understanding, and family pressures. The health system was forced to prioritize temporary contraceptives like condoms and the oral contraceptive pill above longer-term choices like intra-uterine contraceptive devices (IUCDs) and sterilization, especially during the first lockdown, which limited the basket of treatment options for women.

Conclusion

The social backdrop in India substantially influences women’s reproductive behaviour, defining the pressures, limits, and options available to them. Gender-biased norms and practices that regulate family matters severely limit women’s ability to exercise their reproductive rights. At a higher level, there are various apparent inconsistencies in how policies are made, services are offered, and how demographic trends and aspirations concerning family size and composition impact contraception and abortion demand. Despite the fact that India was one of the first countries in the world to adopt legal and regulatory frameworks ensuring access to abortion and contraception, women and girls still face major obstacles to fully exercising their reproductive rights – it is time to change that. Let us vow to support and steer reproductive rights on this Human Rights Day, not only because we want healthier women, but also because we want empowered women and girls.

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Why the amended abortion law in India restricts access and fails to grant pregnant (women, transgender and nonbinary) persons, complete control over their reproductive choices.

Mani Chander

The Medical Termination of Pregnancy (Amendment) Bill, 2020 was approved by the upper house of the parliament and received presidential assent in March, 2021. Some of the amendments brought in by the new Act were hailed by many for further liberalizing access to abortion in India. On the other hand, some leaders of the opposition had voiced concerns, demanding a detailed scrutiny of the Bill by a parliamentary standing committee. The Bill, however, was passed without any further deliberation or amendments.

One of the key amendments brought by the Act was in terms of easing the process of approval by doctors. While the earlier law required one doctor’s approval for pregnancies up to 12 weeks and two doctors’ for pregnancies between 12-20 weeks, the new law requires only a single doctor’s approval for pregnancies up to 20 weeks. The approval of two doctors is now needed only for the 20-24 timeline reserved for abortion seekers of special categories such as rape or incest survivors. The upper gestation limit for abortion in cases of foetal disability has also been removed.

The other significant change introduced by the new Act was the mandatory constitution of a medical board in every State and union territory (UT), which would decide on pregnancies beyond 24 weeks in cases of foetal abnormalities. As per the amended act, the board would have one gynaecologist, one radiologist or sonologist, one pediatrician, and other members as prescribed by the respective state or UT.

Nearly six months since the new act came into effect, several issues around the revised mandate have come up, showing that the new law, though well intended, continues to restrict reproductive rights. 

The first obvious and fundamental drawback is that our lawmakers have failed to recognize that reproduction is not just a women’s issue. Seeing only women as natural mothers is exclusionary and deeply problematic as it ignores the fact that trans and non-binary persons can also become pregnant. It reinforces harmful stereotypes around reproduction and sexuality.

Furthermore, while the establishment of medical boards in every state and UT seems like a noble idea, ground reality points to its infeasibility. A recent report based on the Ministry of Health and Family Welfare’s Rural Health Survey, which analyzed district-wise availability of medical specialists, found that there is a severe shortage of doctors. As many as 82% of these posts for surgeons, obstetricians, gynaecologists, physicians and paediatricians lie vacant. In rural India, where 66% of the country’s population resides, there is a shortage of approximately 70%. While states like Arunachal Pradesh, Meghalaya, Mizoram and Sikkim revealed a 100% shortfall of pediatricians, others such as Tamil Nadu, Arunachal Pradesh, and Gujarat have recorded near-absolute absence of certain specialists in rural areas.

Besides, even if the state governments manage to set up the necessary medical boards, access will remain a challenge, particularly for those in remote areas. It is noteworthy that the new law fails to include any provision whatsoever for ensuring logistical or financial assistance to those who need to consult a medical board. Rather than ensuring access and convenience, forcing pregnant persons to run around in search of medical boards would create further hurdles for them.

Not to mention that these medical boards have no clear mandate, leaving the scope of their functions excessively wide. Absolute discretion when considering requests for abortion allows medical boards to venture into subjective issues such as viability of the foetus and possibility of corrective surgery. 

Time and again, courts have reiterated the right of a woman to control her body and fertility. In 2016, the Bombay High Court in a suo moto public interest litigation held that “the right to autonomy and to decide what to do with one’s own bodies includes whether or not to get pregnant and stay pregnant”. It flows logically, that any encroachment of bodily autonomy would also amount to infringement of privacy, as observed in the Puttaswamy judgment of the Supreme Court.

While restrictions on the fundamental right to privacy may be imposed on account of larger interests, they ought to be “just, reasonable, and fair.” It appears, however, that the amended Act, if challenged, would fail to satisfy this constitutional mandate.

Contrary to their own precedents upholding bodily autonomy, courts have sometimes rejected petitions seeking approval for abortions. The reason is that courts ultimately rely on the decision of the medical boards, while ignoring the advice of the woman’s own gynaecologist. For instance, the Supreme Court rejected the termination of a 27-week pregnancy even though the foetus had severe physical abnormalities, because the medical board had found that there was no physical risk to the mother. The same fate was met by a 25-year-old woman whose foetus was diagnosed with Arnold Chiari syndrome, an abnormality that leads to underdeveloped brain and distorted spine.

Moreover, the process of setting up medical boards and delayed decision-making has forced women to carry their pregnancies to term. In one case, an HIV-positive rape victim from Bihar, who was denied abortion when she was 18 weeks pregnant, was forced to give birth as a result of delay. While awarding compensation to the woman, the Supreme Court remarked, that “the fundamental choice (of termination of unwanted pregnancy) which is available in law was totally curtailed and scuttled, ..the entire action has caused her immense mental torture”. In another case, after the Supreme Court allowed abortion of a 13-year-old rape survivor, she ended up giving birth two days later. Bureaucratic delays coming in the way of women’s reproductive rights can hardly be considered just. 

In yet another striking suit, the top court refused to allow an abortion for a 10-year-old girl, allegedly raped by her uncle, because the medical board was of the opinion that termination would be “too risky”. What medical boards and courts seem to be ignoring is that in most cases involving children, the pregnancy itself is discovered too late because they are unaware of their condition. Yet, they are made to pay the price for no fault of their own.

The central argument is that medical boards and doctors continue to decide and make the final call. Leaving the decision to anyone other than the woman grossly undermines her dignity and agency, particularly when those assigned the task of decision-making are not bereft of their own personal and moral beliefs. 

India is considered to have a fairly progressive abortion law when compared to other countries, yet it is regressive in more than one way. While we still have a long way to go, we mustn’t hesitate to learn lessons from the rest of the world. Texas’ recent law which effectively bans abortions is a painful reminder that hard-won rights can be stripped away all too easily. 

We cannot be complacent, for we are not free until all of us are.

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*Views are personal. The author is a Delhi-based practicing lawyer who holds a special interest in gender justice. She holds a Master’s degree from the University of Virginia School of Law and is admitted to the Bar Council of India as well as the New York State Bar.

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