Inside a school at Kutai village in Madhya Pradesh's Satna district, 20-odd girls are listening intently as a young woman takes them through the bodily changes linked to puberty. The audience gathered is between the age group of 15-24, a group which accounts for about a fifth of India's total female population.
Barring two, the rest are single. Preeti Singh, the mother to a three-year-old, never misses these sessions. “I have learned about menstrual hygiene and about pills that delay babies," says the 23-year-old, who had a baby within a year of her marriage. "My husband didn't want a baby either, but we thought abortion was illegal."
It is misconceptions like these that are being addressed in small gatherings held across rural Madhya Pradesh. Even though abortion is legal in India since 1971, ten women in the country die every day due to unsafe abortions performed by quacks and untrained "doctors". According to an IndiaSpend report, 56 percent abortions in India are unsafe.
The problem, believes Dr Nozer Sheriar, lies in the larger failure to communicate that abortion is legal. "Study after study has confirmed that many women in India think that abortion is illegal. There is no public campaign telling them otherwise. While there’s a lot of noise about the PCPNDT Act for instance (the Pre-Conception & Pre-Natal Diagnostic Techniques Act, against sex-selective abortions), or POCSO Act (Protection of Children from Sexual Offences Act) there’s not enough talk about the high risks of unsafe abortions," says Sheriar, who is the former chairperson of the MTP (Medical Termination of Pregnancy) Committee and former secretary general at Federation of Gynaecologists and Obstetrician Societies of India (FOGSI).
Youth leaders in Madhya Pradesh, trained by Ipas Development Foundation (IDF), are addressing this very knowledge gap. Since 2006 IDF has been working with the government to improve comprehensive abortion and contraception care. Madhya Pradesh is among six states where the maternal mortality rate is higher than that of India — 221 compared to 167 deaths per 100,000 live births.
The state government and IDF began a concerted effort to ensure access to safe abortion services at all public health facilities. Key interventions involved training physicians, nursing staff, providing essential equipment and drugs, and messaging on the availability of services.
"Our understanding was that if we make services available, women will come forward," says Vinoj Manning, CEO, IDF. "There were huge gaps in rural areas and the focus was on addressing that."
However, over time a need was felt for more direct intervention. "Women did not know abortion was legal, many even believed it was a sin, so a need was felt for a multi-pronged campaign to normalise abortion, so that young girls and women seek it like any other service," Manning adds.
This led to the start of a youth leadership program in July 2018. Men and women from the community are trained to carry out sensitisation programmes using tools like stories with flip charts, and games, to make the sessions informative and engaging.
Twenty-three-year-old Smita Singh, who is a masters student, signed up last November. "Growing up, I did not have access to this information, and I found out in college," she says. Smita starts with lessons on menstrual hygiene, bodily changes in boys and girls during puberty and then talks about abortion. "Many unmarried girls come up to me separately with questions about various methods of contraception, some tell me they have been to a quack for an abortion."
There was some initial resistance. "Once a group of women demanded to know why I was talking about such matters," recalls Smita. She reassured them that the information was important for their daughters’ health and safety.
Over time, Shahina Bano, 28, a youth leader from Satna, has built a close relationship with the community. “Many girls are scared to visit government health facilities on their own, so I tell them to come on days when I am on duty and take them to doctors myself." She cites the instance of a girl who had heavy periods every 15 days but didn’t know where to seek help. “I took her to the doctor, and she was given medication and was given a diet to follow."
An earlier program on the same lines in two regions of Jharkhand has shown promising results. Awareness about the fact that abortion is legal grew from 12 percent to 60 percent in one region, and 3 percent to 30 percent in the other. Information about abortion-related issues rose from 9 percent to 82 percent and 2 percent to 34 percent. This was over the span of two years.
The sustained intervention has led to a fall in the rate of unsafe abortions, says Raj Kamal Sharma, senior state director, IDF, Madhya Pradesh. Awareness among officials has grown as well.
"When we started in 2006, leave aside doctors, even some district health officials were confused about the scope of the MTP Act, and would sometimes issue orders that abortions were to be stopped on grounds of illegality," says Sharma. "There was no knowledge of WHO guidelines, of legal rights of women, the importance of consent forms."
Another factor complicating the service delivery mechanism further was the enormous paperwork, with women being asked to provide voter IDs, ration cards, and ultra-sonography details. All this has been done away with.
However, barriers still remain at PHCs, the first point of contact for the community. This forces 69 percent women to access services at non-facility settings, says a 2018 Guttmacher Institute report. Provision of abortion services in PHCs in Madhya Pradesh was the lowest among the six states surveyed.
This, experts say, points to the need to move away from medical doctors to mid-level providers.
“With medicated abortions approved, infrastructure has been taken out of the equation”, points out Dr Sheriar. “We have 81% of abortions happening this way in India, which means safe abortions cane be delivered to women wherever they are. 85-90% abortions take place in the first trimester, so mid-level providers can take charge’’.
The huge gap between supply and demand makes the argument a strong one. Medical Council of India figures show that while more than 16 million abortions are carried out annually, only a fraction of the eight lakh doctors in service conduct abortions.
“It’s clear that we don’t have the numbers or the capacity”, adds Dr Sheriar. “It’s time we recognise the capacity of mid-level providers or doctors who have studied alternative methods of medicine, and make them accountable’’.
The medical fraternity has resisted this move, despite WHO recommendations. “There are 17-18 countries where this has been successful, including Nepal, Bangladesh and South Africa”, points out Manning.
Besides, a Population Council study in five facilities in Bihar and Jharkhand where nurses were trained in manual vacuum aspiration (MVA), a form of induced abortion, showed successful results. It showed that nurses are as skilled as doctors in assessing gestation age and completed abortion status, performing MVA, and obtaining patient compliance.
Such findings make a compelling case for amending existing laws so that more women have access to safe abortion in India.
The author edits NewzHook, India’s first accessible news website for disabled people, with news in sign language.
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Updated Date: May 13, 2019 16:47:08 IST