Why abortion should be a part of Universal Health Coverage
The article has been authored by Debanjana Choudhuri, climate and gender specialist and Vithika Yadav, campaign advisory group member, Pratigya Campaign for Gender Equality and Safe Abortion.
Access to abortion is an unconditional human right and should be entitled as a basic health care service delivered as a part of Universal Health Coverage (UHC). UHC is a commitment to equity and focuses on ensuring a level of quality care that helps people achieve their desired health outcomes.
While on the surface it looks easy, pro-choice, abortion, and autonomy over women’s body face barriers in the generational prejudice against women, existing taboos, and pedagogical approach towards a division of labour. These various components of disparities have led to the gross neglect of women’s health, and the most overlooked is the Sexual and Reproductive Health Right (SRHR), which is essential to the fulfillment of universal health coverage and is included in the Sustainable Development Goals, which commit countries to providing universal access to sexual and reproductive health services by 2030.
To bring it within the purview of UHC, we first need to start prioritising women’s health, and the autonomy on her body, have safe space discourse on SRHR, and make comprehensive abortion care a critical part of our general health and wellness.
This suggestion comes against the background of data-based evidence which shows the gender bias suffered by Indian women in accessing health care. According to a 2016 study, researchers from India and Harvard University looked at the year-long records of 2,377,028 outpatients who visited All India Institute of Medical Sciences (one of the largest public hospital and research institute in Delhi). The findings reflected that only 37% of women accessed health care services, as compared to 67% of men. Furthermore, the study heightened the gender bias in terms of region, meaning states like Bihar or Uttar Pradesh (UP), witnessed a lower number of women patients reporting for treatment as compared to Delhi, owing to the added costs of travel. Gender-induced affordability, avoidance of social stigma and labelling, living with the burden of expectations point towards lower number of women seeking formal health services or treatment were other deterrents to women accessing healthcare as highlighted in the study.
Various other studies paint a rather grim picture in context to access to abortion. It is noteworthy to state that simple, safe and effective interventions exist for abortion care yet unsafe abortions is among is among the foremost cause of maternal deaths in India. A 2015 Lancet study shows that of the 1.56 crore abortions accessed annually in India, 78% or 1.23 crore were conducted outside the health facilities.
Another report by the ministry of health and family welfare, in 2015 , which studied the data between 2001 and 2004 shows that 56% abortions in India are unsafe and an average of 10 women die daily due to unsafe abortion practices. Global data also validates that an estimated 56 million induced abortions occur every year.
Considering the quantum of these unsafe procedures, it is critical to bring it within the purview of UHC, which can directly address the economical constriction which many women continue to face, due to lack of financial independence. As witnessed in all these years, along with the social and financial barriers, there are legal barriers which women face when going for abortion. While one aspect of UHC addresses the financial autonomy, the coverage for comprehensive abortion care should start with accessibility and education, simultaneously; and the judicial system has a big role to play in this.
If we take a closer look at the amendment of Medical Termination of Pregnancy (MTP) Act in 2021, abortion is legalised under various conditions upto 24 weeks. However, the law does not guarantee greater access. On the contrary, it gives reasons based on which a pregnancy can be terminated:
If it involves the risk of life to the pregnant women or grave injury to mental health
If pregnancy is as a result of rape or failure of contraceptive used to limit the number of children
If the unborn is at a risk of serious mental or physical abnormality
The law doesn’t give much scope of deviation and clearly restricts autonomy on women’s body, as the MTP Act mandates the opinion of certified medical practitioners. In case the gestational period is between 20-24 weeks, then certification from at least two medical practitioners is required.
While it is a progressive bill in terms of abortion rights in India, the true measure of success depends on the implementation and its ability to bridge gaps. A lot of work remains to be done in terms of access, rights-based approach, telemedicine, and task sharing. Therefore, the judiciary continue to play a central role responsibility in furthering access to safe abortion.
Although at a micro-level, it is being observed that despite the law, women continue to face obstacles and delays to get an abortion, and therefore are forced to resort to legal measures. From a public health and human rights viewpoint, abortion is essential health care, and the Covid-19 pandemic has clearly reaffirmed this. There is evidence to suggest that prior to the pandemic, there were at least 500 cases of pregnant women knocking the doors of justice across the country seeking permission for termination of pregnancy, which resulted either due to rape or because of severe foetal abnormalities, endangering the life of the mother or child or both in some cases.
Women’s health has never been apriority in our country. With little investment in women's health several Indian states like Rajasthan, UP, Madhya Pradesh, Chhattisgarh, Bihar, Odisha and Assam continue to record very high maternal mortality rates, and there is a direct correlation to unsafe abortion.
The right of a woman or girl to make autonomous decisions about her own body and reproductive functions is at the core of her basic rights to equality, privacy, and bodily integrity. This is clearly not happening for most women in India. It is time to have a gender-sensitive mass movement, across the board taking a bottoms-up approach, right from strengthening of local health care at the district level, where is woman can get free and fair access to health services to taking a rights-based approach at a national and global level.
To achieve this, it is essential to include safe abortion care with all other components of health care. Women should have ready access to information and services required to make informed decisions about their lives, including their individual sexual and reproductive health. Abortion care in India must be strengthened, in terms of clinical competency and infrastructure as well as the provider's understanding and acceptance of the need to provide safe abortion care.
(The article has been authored by Debanjana Choudhuri, climate and gender specialist and Vithika Yadav, campaign advisory group member, Pratigya Campaign for Gender Equality and Safe Abortion.)