Abortion Law, Policy and Services in India: A Critical Review Author(s): Siddhivinayak S.

Hirve Reviewed work(s): Source: Reproductive Health Matters, Vol. 12, No. 24, Supplement: Abortion Law, Policy and Practice in Transition (Nov., 2004), pp. 114-121 Published by: Reproductive Health Matters (RHM) Stable URL: http://www.jstor.org/stable/3776122 . Accessed: 08/03/2013 08:05
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? 2004 Reproductive All rights HealthMatters. reserved. HealthMatters 2004;12(24 Supplement):114-121 Reproductive matter $ - see front 0968-8080/04 PII: S0968-8080(04)24017-4 ISBN 0-9531210-2-X

HEALTH

REPRODUCTIVE

matters

www.rhmjoumal.org.uk

inIndia: Abortion andServices Law,Policy A Critical Review

S Hirve Siddhivinayak
VaduRural KEM Health India. E-mail: sidbela@vsnl.com Director, Pune, Programme, Hospital,

Abstract: 30 years of liberal themajority of women in Indiastilllackaccess legislation, Despite to safe abortion care.This reviews thehistory law and policy in of abortion papercritically on abortion in 2002 and 2003 to Indiasincethe 1960sand research service Amendments delivery. the 1971MedicalTermination ofPregnancy devolution ofregulation of abortion Act, including services to thedistrict measures todeter ofunsafe rationalisation level, abortions, punitive provision ofphysical forfacilities to provide and approval of medical abortion, early requirements haveall aimedto expand safeservices. amendments to theMTP Actto prevent abortion, Proposed and violated sex-selective abortions would havebeenunethical and confidentiality, werenot include taken forward. of bothpublic and private sector Continuing problems poorregulation a physician-only thatexcludes mid-level and lowregistration of rural services, policy providers all restrict access.Poorawareness to urban of thelaw,unnecessary clinics; spousal compared consent linked to abortion, and informal and highfeesalso targets requirements, contraceptive serveas barriers. more clinic Training registration de-linking providers, simplifying procedures, and provider and linking with research and good clinical technology, approval, policy up-to-date are someimmediate measures neededto improve access to safe abortion women's practice Allrights care.? 2004 Reproductive Health Matters. reserved. abortion law and policy, abortion vs. private of sex services, sector, public prohibition Keywords: India determination, HE IndianPenal Code 1862 and theCodeof Criminal Procedure origins 1898,withtheir in the British Offences againstthe Person a crime Act 1861,made abortion for punishable boththe woman and the abortionist exceptto save thelifeof thewoman.The 1960s and 70s saw liberalisation ofabortion laws acrossEurope and the Americaswhich continuedin many oftheworld the1980s.1'2 The other through parts of abortionlaw in India began liberalisation morin 1964 in the contextof high maternal abortion. Doctors due to unsafe frequently tality came across gravelyill or dyingwomen who had takenrecourse to unsafeabortions carried that outbyunskilled Theyrealised practitioners. were the majority of womenseekingabortions to married and underno socio-cultural pressure
114

concealtheir and thatdecriminalispregnancies would encouragewomento seek ing abortion abortion services in legal and safesettings.3 TheShahCommittee, bytheGovernappointed outa comprehensive ment ofIndia,carried review of socio-cultural, legal and medicalaspectsof and in 1966 recommended legalising abortion, abortion to prevent wastageof women'shealth and medical and lives on both compassionate someStates lookeduponthe grounds.4 Although as a strategy forreducing proposedlegislation Shah the Committee growth,5 population specifiThe term callydeniedthatthiswas its purpose. of Pregnancy" "MedicalTermination (MTP)was used to reduceopposition fromsocio-religious of abortion law. groupsaverseto liberalisation in 1971, The MTP Act, passed by Parliament

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SS Hirve Health Matters / Reproductive 2004;12(24 Supplement):114-121

abortion in all ofIndiaexcept thestates stantial riskthatthechild, ifborn, wouldsuffer legalised ofJammu and Kashmir. from or disease.The law allows any deformity maintained to perDespitemorethan 30 years of liberallegis- hospital by the Government themajority ofwomenin India form but requires abortions, lation, however, approvalor certificare.Thispaper cationofanyfacility in theprivate stilllack access to safeabortion sector. reviews thehistory ofabortion law and In theevent ofabortion to save a woman'slife, critically in India (Box 1), and epidemio- the law makesexceptions: the doctorneed not policyreform the of care studies since the 1960s. have ortraining butstill and logical quality stipulated experience It identifies barriers to good practice and recom- needsto be a registered medical allopathic pracmends a second opinionis not necessary for necessary titioner, policyand programme changes to improve accessto safeabortion care. abortions need beyond12 weeksand thefacility nothave prior certification. The MedicalTermination of Pregnancy Rules of Pregnancy The MedicalTermination andRegulations thecriteria andpro19757 define Act 1971 and Regulations 1975 forapproval ofan abortion facility, profullpro- cedures The MTP Act (No.34 of 1971)6 confers cedures for records and reports, consent, keeping tection medical to a registered allopathic practi- and ensuring confidentiality. Any termination tioner againstany legal or criminal proceedings of done at a hospital or other pregnancy facility forany injury causedto a womanseeking aborwithout of the Government is prior approval that theabortion was donein good tion, provided deemed and the onus is on the to illegal hospital of theAct.TheAct allows faith undertheterms obtainprior approval. an unwanted to be terminated pregnancy up to 20 weeks of pregnancy, a second and requires doctor'sapprovalif the pregnancy is beyond Abortion in India 1970-2000 12 weeks.The grounds includegraveriskto the The initial 1972to 1986after yearsfrom legalisaor mentalhealthof the womanin her physical tion of abortion showed a marginal increase only actualorforeseeable as when environment, pregin the number of abortion (8-10%) approved from or on failure, nancy results contraceptive and the number of abortions reported humanitarian or if pregnancy results facilities grounds, those facilities. In the late 1980s and contrast, by froma sex crimesuch as rape or intercourse 90s showed a trend in the number of declining with a mentally-challenged oron eugenic woman, abortions in facilities.6 In reported approved wherethereis reasonto suspectsubgrounds, of approved facilities were 1997,sometwo-thirds urban-based clinics,reflecting ongoingserious in urbanvs. ruralaccess to approved inequity Box 1.Abortion events inIndia policy abortion in a stillpredominantly facilities rural In themid-1990s, 1964 - Ministry ofHealth less than 10% of the andFamily constitutes country.8 Planning estimated totalnumber Shah Committee ofabortions werereported to the government.911 Data on abortions occur1966 - Shah Committee report outside facilities are rare and ring approved 1971 - MTP Actpassed unreliable. Estimates the beginning datingfrom of the 1990s to morerecent 1972 - MTP Act enforced inallofIndia Jammu years are largely except and have rangedfrom2-11 illegal andKashmir speculative abortions for performed every legalabortion.3,12,13 1975 - MTP Rules andRegulations framed Thus, althoughit may not be the case that 2002 - MTP Act (Amendment) abortions in unapproved facilities are all unsafe, it can still be assumed that safe abortion care - Mifepristone for medical abortion approved by is still not widely available. In most states, Controller ofIndia General Drug less than 20% of primary healthcentres pro2003 - MTP Rules andRegulations amended vide abortion services.14,15 Even wheretheydo 2004 - National consensus to seek abortionin the prifor medical so, womenprefer guidelines vatesector, to under-utilisation abortion ofpublic (under development) leading facilities. thequality of abortion services Further,
115

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SS Hirve Health Matters /Reproductive 2004;12(24 Supplement):114-121

and provideor be able to refer complications women to facilities care. capableofemergency Theamended MTPRulesalso recognise medical abortion methods and allow a registered medical to provide practitioner (e.g.thefamily physician) + misoprostol in a clinicsetting to mifepristone to terminate a pregnancy seven weeks, up provided thatthe doctorhas either on-sitecapability or accessto a facility capableofperforming surgical in the eventof a failedor incomplete abortion of medical abortion. theDrugController However, Abortion law reform since2000 Indiahas approved only mifepristone provision by India has committeditself to safeguarding a gynaecologist, thuseffectively access restricting in human and reproductive to women in urban areas. Nationalconsensus rightsarticulated forums.22-25 After a long guidelines and protocols28 formedicalabortion variousinternational various are consultative being involving process governcurrently developed. and non-governmental mental agencies, professionalbodiesand activists, theIndianParliament lawand policy: whatis of Pregnancy Current enactedthe MedicalTermination still missing? Act 2002 and amended Rules and (Amendment) A majorcriticism of the MTP Act is its strong Regulations 2003.26'27 In an effort to reduce the bureaucracy for medicalbias. The "physicians only" policyfor excludes mid-levelhealth providers the new Act providers obtainingapproval of facilities, of alternativesystems of decentralised regulationof abortionfacilities and practitioners of a secondmedical The requirement from Committees that medicine. the Statelevelto District abortion further are empowered to approveand regulateabor- opinionfora secondtrimester in ruralareas. measures restricts It also provides tionfacilities. access,especially punitive The MTP Act mandatesthe State to provide forindividual of 2-7 yearsimprisonment proabortion servicesat all public hospitals.Hownot approved vidersand ownersof facilities by To reduce ever,the lack of required or maintained approvalforpublic by the Government. thepublicsectorfrom theamended MTPRules27 healthfacilities administrative exempts delays, thatapplyto the and man- thesame regulatory definea timeframeforregistration processes that a health a facility privatesector.The assumption Committee to inspect date theDistrict of beingin thepublicsecof receiving an application institution within two months by virtue to the public,and has wellwithin toris accountable and process theapproval forregistration ifno deficiencies arefound, functioning thenexttwomonths processesthat do not regulatory is notcorrect. inlaw andpolicy, of any needexplication after rectification two months or within tend to be defunct such the amendedMTP Often, noted deficiency. However, regulations any In the contextof poor measuresto be taken if or lack transparency. Rules do not specify the carein thepublicsector,8'29 abortion in are stillnot completed quality approvalprocedures shouldbe applied as same exactingstandards timeframe. thestipulated fora facility standards Whilephysical provid- in the privatesectorand subjectto the same oftheprivate thatareexpected remain the same auditprocedures abortions second trimester ing sector in theprivate however, table, abdominalor gynaecological sector. Ironically, (operating and often forgeneral India also remains vastlyunregulated Boyle'sapparatus equipment, surgery to adhereto autoclave,drugsand suppliesfor lacks the self-discipline necessary anaesthesia, in the law. standards the MTP Rules the amended resuscitation) specified quality emergency A majorgap in abortion for the physicalstandards rationalise policyin Indiais the required are no longer lack of explicitpolicy on good clinicalpracabortions. Facilities first trimester Nationaltechnical of managing tice and research. to have on-site guidelines capability required withWHO's in 200130 do notconform However, every facility published emergency complications. and failto ensure trainedto recognise international needs to have personnel good guidance31 116

in boththe public and privatesectorsis often oftechnique used,counselling, poorinterms priThemajority ofdoctors vacyand confidentiality. still prefer dilatationand curettage (DEtC)for withless thana quarter of proearlyabortion, vidersreportedly vacuum using aspiration.8'16 ofthelegality of abortion Awareness is low and aboutthelaw among women and misconceptions areprevalent.17-21 providers

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abortion clinical evenat approved facilipractice ties.Consequently, 39-79% of curettage sharp by and continued use of generalanaesproviders8 in 8-15%/o ofreported abortion facilities thesia are still Indiahas simply notfound a way prevalent.32 to ensure theuse ofimproved and safer abortion about research and through practices brought continuously evolving reproductive technology.

law and policy: Abortion and potential actualabuse

In the 1960s,abortion discourse was influenced concerns. largelyby medicaland demographic Thehumanand reproductive rights agendatook centre TheNational stagepost-ICPD. Population thepromotion PolicyofIndia200033encourages offamily services to prevent unwanted planning but also theimportance recognises pregnancies, of provision of safe abortion services whichare accessibleand acceptable for women affordable, who needto terminate an unwanted pregnancy. In India,thoughabortion is legallypermissible undera widerangeof situations, thedoctor has the finalsay. A woman has to justify thather pregnancyoccurreddespite her having tried to prevent it or thatit had been intended but circumstances or made it unwanted changed Thereality later. was maybe thatthepregnancy unwanted from thestart, buttojustify abortion within thelegal framework, thewomanmayfeel she has to say it was contraceptive failure, an environment of falsehood. creating Abortionlaw is always open to differing and thoughthe presentsociointerpretations allows a more liberal political environment in most is alwaysthe cases,there interpretation theoretical ofmorerestrictive danger interpretationsunderdifferent and demosocio-political without a singlewordof graphiccompulsions, the textof thelaw beingaltered.34 Even today, Section 3 of the 1971 Act does notdeny although abortion careto unmarried or separated women or widows,the use of the phrase"Whereany occursas a resultof failure of any pregnancy deviceor method used by any 'married' woman or herhusbandforthe purposeof limiting the number of children..."maybe misconstrued to services to unmarried womenor denyabortion woman's husband'sconsent. requirea married Though activists have argued for replacing "married woman"with "all women", thisrecom-

mendation has not yet been taken up by the as itwouldimply tacitrecognition Government, and sanctionof sexual relations among those who areunmarried orwerepreviously married. Another area of potential abuse of woman's is the mandatory reproductive rights reporting of post-abortion use required contraceptive by MTP regulations (Form2), whichthe Statemay use to compel abortionproviders to achieve Such monitoring often targets. family planning results in a form of coercion of womenseeking in thepublicsector.17 abortion, especially

Abortion care,as withmuchof healthcare in in thepublic India,remains neglected, especially sector.Poor qualityof care and a poor work ethos in the public healthsectorcompounded to implement legislation (orfailure byineffectual in an unregulated of it) have resulted growth sector services which is often private exploitative in nature. India's abortion Although policyand law are progressive, effective translation into access to safe abortion care is often improved andunnecessary impeded bymisguided practices. The law empowers state governments to services. regulateabortion Thoughstateshave adaptedtheserulesand regulations, theydiffer in their interpretation and implementation. Withtheintent of ensuring and preventsafety some Stateshave added ing unsafeabortions, and created layersof non-essential procedures administrative in the delays regulatory process and unnecessarycontrols. Maharashtra,for there to be a bloodbankwithin example, requires 5 km of any abortionfacility, a requirement thatis bothimpractical and unnecessary. Some States- Delhi and Haryana- require the floor area and architectural and plans of thehospital detailsof provision of car parking to be submitted forregistration.35 The overallmindset of these Statesis to control rather than facilitate abortion services. The discriminatory natureof such overzealousregulation becomes apparent whentheserequirements are appliedonlyto the sector and not the private publicsector. The timeand effort neededto procure certification of an abortion also reflects the facility States' andapproach attitude towards abortion. In for thecerspiteofthenewtimeframe specified tification bureaucratic process, mismanagement, 117

Barriers inabortion service delivery

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lack of responseand corruption are purpose ofsex determination whichmaylead to hurdles, A encountered.29 nationwide the abortion of fetuses. TheseActs also female study commonly in 1999 of 118 abortion of such use of thesetests; facilities revealedcer- prohibit advertising 1-7 years.36 tification from How- require all facilities usingthemto be registered delaysranging in six States and prohibit such teststo ever,a recentsurveyof facilities personsconducting of fetus. indicated different. reveal the sex the something surprisingly quite Ofthe285 private thosewho surveyed, Though the purposes of the PNDT laws providers sex determination) and the MTP hadbeenabletodo so within (prohibiting werecertified (25/%) safe abortion)are distinct, a month. a third had Act (ensuring they Amongthosenotcertified, linked. Followtriedand given up or were still awaitingcer- were almost inappropriately two-thirds had not ing a Public Interest The remaining tification. Litigationsuit filed in Court either indifference the Supreme eventried to apply, by Dr Sabu Georgeand the reflecting towards ora gen- NGOsCEHATand MASUM in 2000 againstthe ora casualattitude certification, to implement of Government of India forfailure and reporting eral dislikeof record-keeping review discussed PNDT a the to the rather State, Act, meeting policy post-abortion complications MTP Act to sex-selective the as their reason than cumbersome prevent modifying procedures One Low awareness abortionfollowingsex determination.42 fornot seekingcertification.37 was to allow abortiononly up to about the law (e.g. that suggestion and misconceptions to prevent sex-selective iftheywork 12 weeksofpregnancy, need not seek certification doctors amniocentesis or sonograor onlydo an occasionalabor- abortions in smallclinics, following of pregnancy, which women phyin thesecondtrimester formarried tion, or provideabortions included fetal sex. Other in low certifi- can identify factors thatresult suggestions only)are other of any woman seeking the identity cationlevelsofsomefacilities.38 reporting fetus. as well as thesex of theaborted law norpolicybutpro- abortion it is neither At times, barriers to access. However,expertsresolvedthat therewas no who creates themselves viders thelaw does notrequire Though implemenspousalor any needto amendtheMTPAct,as strict third exceptin tationof thePNDTActwas whatwas required. partyconsentfora termination would have the woman's identity in reality, abortion thecase ofa minor, providers Reporting based on "common been a violationof confidentiality. insist on suchconsent often Restricting would to 12 weeksof pregnancy beliefof the law". Reasonsoftencitedforpro- legal abortion womenover12 weeksto seekillegal on spousal consentincludethe have forced viderinsistence reasons no matter whattheir abortion themselves need to safeguard services, againstsocial and health obvious with for from abortion abortion, consequences. arising complicalegal problems wouldnot fetus thesex oftheaborted ofwomen Recording andthelowsocialstatus ordeath, tions but also would have on their husbands. and their onlyhave been unethical dependence feescharged so-calledinformal bypro- made abortionscarriedout for otherreasons Lastly, have made access and might or exorbitant vidersin thepublicsector charges suspect, indirectly overall. moredifficult services in the private sector that exploit women's to safeabortion and low awareness of the law, vulnerability theunwanted where in circumstances especially thewayahead lawand policy: also add Abortion is not sociallyacceptable, pregnancy notradical, lawandpolicy Recent to access.39 barriers reforms, though a towards a stepforward stillrepresent ensuring care.It is onlyin to safeabortion woman'sright and sex determination: Abortion consultanational-level recent yearsthatseveral issues different tiveefforts43-46 involving profespolicymakers, of Obstetrics The Prenatal (Regulation sionals bodies like the Federation Techniques Diagnostic of India (FOGSI)and Societies Act(PNDTAct)199440 and Gynaecology ofMisuse) andPrevention Association Medical Indian the the amended (IMA), NGOs was later which Pre-Conception by ParivarSeva Sanstha,CEHAT,Health and Determination (notably Sex Selection and Pre-Natal of Association Act200241prohibits Watchand the FamilyPlanning andRegulation) (Prohibition the have championed testsforthe India)and healthactivists, the misuseof antenatal diagnostic
118

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SS Hirve Health Matters 2004;12(24 Supplement):114-121 /Reproductive

ofaccessto safeand legalabortion awarenessand dispelling misconIncreasing improvement in India.Manyoftheir services recommendations ceptionsabout the abortion law amongstproare in linewiththeobjectives and thestrategies vidersand policymakers is just one steptowards outlined in the ActionPlan of India's National this.Thereis a need to enhanceawarenessof 2000.Theyinclude: both contraceptive and abortion services, Population espePolicy, withinthe larger cially amongstadolescents, * increasingavailabilityand access to safe context of sexual and reproductive intehealth, abortion and interventions within value services, grating strategies * creating morequalifiedproviders and family and gender relations.35'47 (including systems mid-level and For these effecfacilities, providers) especially policies to be implemented in ruralareas, need to be backed tively, they by politicalwill * simplifying thecertification and commitment in terms of adequateresource process, * de-linking clinicand provider and infrastructure certification, allocation, training support, * linking and research accompanied based on women's policywithtechnology by socialinputs and good clinicalpractice, needs.Advocacyand actionat bothcentral and * applying uniformstandards for both the state level are required to put the operational and publicsectors, and relevant to abortion, as detailed in the strategies private * ensuring care. NationalPopulation 2000 intoeffect. qualityof abortion Policy, References

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la majorite liberale, Apres30 ans de legislation des Indiennes n'a toujours pas acces a des avortements surs.L'article retrace l'histoire de la loi et la politique en Indedepuis surl'avortement les annees 60 et la recherche sur ces services. Des amendements en 2002 et 2003 a la Loi de 1971 sur l'interruption medicalede grossesse notammentle transfert aux districtsde la desservices, des mesures reglementation punitives les avortements la clandestins, pour decourager rationalisation des equipements pour pratiquer des avortements et l'homologation de precoces, - visaient l'avortement medical lesservices a rendre les plus surs. Des amendements pour prevenir avortements selectifs selon le sexe du foetus, contraires et a la confidentialite, n'ont a l'ethique pas ete adopt6s. Des problemes chroniques l'acces, par exemplel'insuffisante restreignent des services et prives, une reglementation publics politiquedu f tout medical ), qui exclut les et le faible niveau intermediaires, prestataires d'homologationdes dispensairesruraux par aux dispensaires urbains. D'autresfreins rapport sont l'ignorance de la loi, l'obligation superflue d'obtenirle consentementdu conjoint, des lies a l'avortement et les objectifs contraceptifs cofitselev6s. Pour elargirl'acces a des soins surs,il faut former davantagede prestataires, simplifierles procedures d'enregistrement, des dispensaires et des separerl'homologation et associer la politiqueavec une prestataires, desrecherches etunebonne modeme, technologie pratique clinique.

Resume

Resumen Pese a 30 anos de legislaci6n la mayoria liberal, de mujeres en la India ain carecende acceso a servicios de aborto En estearticulo se revisa seguro. la historia de la ley de abortoy las politicas desdelos sesenta, pertinentes y las investigaciones sobrela prestaci6n de servicios de aborto.Las enmiendas del2002y 2003a la LeydeInterrupcion Medica del Embarazo de 1971, incluida la devoluci6n de la regulaci6nde los servicios al nivel distrital, las medidas punitivaspara obstaculizar la practica de abortos la inseguros, racionalizaci6nde los requisitosfisicos para abortosen etapas iniciales, que se practiquen del abortofarmacol6gico, han y la aprobaci6n los servicios. Las enmiendas procurado ampliar a la leycontra el aborto propuestas porselecci6n delsexono hubiesen sidoeticas violado y hubieran la confidencialidad; por tanto,no se levarona cabo. Entrelos problemas constantes la figuran deficiente de servicios en los sectores regulaci6n la politica "s6lo medicos", piblicoy privado, que de la salud de nivel excluyea los profesionales delas clinicas rurales intermedio, yunbajo registro en comparaci6n con las urbanas;han limitado el acceso.Otras barreras son: poco conocimiento dela ley, innecesarios deconsentimiento requisitos del c6nyuge, blancosanticonceptivos vinculados al aborto y tarifas altas extraoficiales.El mas proveedores, el registro, capacitar simplificar a la clinica de la aprobaci6ndel desvincular las politicas con tecnologia proveedor y vincular actualizada, la investigaci6n y las buenas clinicas son algunasmedidas inmediatas practicas necesarias el acceso de las para mejorar mujeres a los servicios de aborto seguro.

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