Reducing unwanted pregnancies during COVID-19: Rights-based, system-level response need of the hour

The access, availability and affordability of contraceptive and abortion services in India have been negatively impacted by the Covid-19 pandemic, exacerbating existing issues. Currently, the Government of India has considered these health services as essential during Covid-19.

Medhavi Gupta and Deepshikha Chhetri December 13, 2020 16:17:55 IST
Reducing unwanted pregnancies during COVID-19: Rights-based, system-level response need of the hour

Representational image. Reuters

Access to contraception and abortion services has been severely impacted by the COVID-19 pandemic, leading to an increase in unwanted pregnancies. This policy brief outlines the issues being faced by the system of contraceptives and safe abortion services and provides recommendations on actions the state and national governments can take to ensure universal coverage of services.

Methods for managing unwanted pregnancies

Safe contraception and abortion services are essential to the reproductive rights of women, as they address fertility control and reduce unwanted pregnancies. Access to contraception prevents pregnancies from occurring in the first place. However, as no method provides 100 percent protection, abortion services are required to ensure women who do fall pregnant have an option to terminate the pregnancy.

Why is access to contraceptives important?

Almost 137 million women in India use contraceptives each year. Contraceptive services are essential in avoiding the majority of unwanted pregnancies. Permanent contraception methods can prevent women from becoming pregnant long-term (with over 99 percent effectiveness using male and female sterilization). Temporary contraception methods such as condoms and oral contraceptive pills can be used to delay or space apart pregnancies. A range of contraceptives are available globally, which are listed in Appendix A.

Preventing unwanted pregnancies has important implications for both mother and child health. Spacing births using temporary methods by at least 4 years reduces infant mortality by up to 60 percent as families are better able to support the needs of each growing child . Ensuring a minimum of 2 years between births can reduce maternal mortality by up to 33 percent. In addition, large family sizes lead to a range of negative outcomes including strain on local resources, poorer economic outcomes for mothers, poorer educational outcomes for children, increased anxiety for parents, and financial stress . Ensuring families are able to have fewer children and increase the time between each child has family and society-level benefits.

The occurrence of early and child marriages also continues to be an issue in India, and access to contraceptive and abortion services is essential to protect these children. Children (girls under the age of 18) who get pregnant have a higher chance of experiencing complications during childbirth which lead to a range of life-long health problems. Early motherhood also prevents these girls from accessing education and sets them up for a life of vulnerability and dependence on others . Access to contraceptive and abortion services ensure these girls have some autonomy over their bodies and can delay pregnancy until they are older. In this brief, whenever we refer to women, we are also referring to young girl brides.

Why is access to safe abortion services important?

Contraceptive methods may fail and are not always available, and so safe abortion services ensure that women can terminate unwanted pregnancies. Under the Medical Termination of Pregnancy (MTP) Act, 1971, women may terminate a pregnancy with a referral from a doctor. Almost 16 million abortions are carried out in India each year .

There are two main methods of abortion:

- Medical abortion: This method uses pills to terminate pregnancies. The use of medical abortion pills is currently licensed up to 9 weeks in India, but can be used up to 32 weeks as per World health Organization (WHO) recommendations. In many countries, women can self-administer medical abortion pills with access to support on the correct use and post-abortion care. The medical abortion pill is most often purchased illegally without prescription through pharmacies for reasons discussed below. These illegal purchases comprise of up to 75 percent of total abortions in India .

- Surgical abortions: These abortions require a trained and qualified medical practitioner to administer in a clinical setting and are conducted on later-term abortions.

Women looking to terminate an unwanted pregnancy may be forced to use unsafe methods if they cannot access safe abortion services. In 2015, an estimated 11.5 million women in India accessed abortion outside of health facilities, and 0.8 million of them used unsafe methods such as at-home abortions and abortions conducted by untrained providers . This is a major cause of maternal death and disability, which can be avoided if access to safe abortion was universal.

What did contraception and safe abortion services in India look like before COVID-19 ?

Access to contraceptive and safe abortion services is provided under the National Health Mission for free. However, access to modern methods of contraception and safe abortion services are inadequate and discriminate against poor and marginalised groups.

Contraceptive services

The provision of contraceptive services is covered under the National Health Mission. The majority of contraceptive services in India are provided through public services. The methods provided include: oral contraceptive pills, condoms, intrauterine contraceptive devices (IUCDs), injectable contraceptives, and male and female contraceptives . Appendix A summarises all types of contraceptives and details how each is available in India.

Only between 10-20 percent of people using contraceptives use temporary methods such as oral contraceptives or condoms . The most commonly used contraceptive method used continues to be permanent female sterilisation, accounting for between 60-70 percent of the methods employed in India . This focus on permanent methods reflects a systemic problem of both lack of access and awareness of temporary methods available.

Despite policy assurance of access to contraception, there is still great unmet need. It is estimated that half of all pregnancies in India are unwanted each year . Unmet need is a measure of the number of sexually active fertile women who do not have access to contraceptives but want to delay or prevent pregnancy. This rate is about 13 percent in India .

Increasing the access and variety of contraceptive methods used is essential to reduce unwanted pregnancies. However, there are a range of reasons why people are not able to access contraception:

  • The Ministry of Health and population policy has heavily encouraged the use of permanent contraceptive methods in the past, and many women are unaware of the range of temporary methods that should be made available to them . Women (and their families) are often unwilling to commit to permanent methods.
  • Lack of education has meant there are misconceptions regarding the side effects of temporary contraception methods, and many women believe they make you permanently infertile.
  • Poor connectivity and conservative attitudes prevent women from accessing temporary contraceptive methods regularly in rural regions where women have less mobility and independence. Women are unable to travel to markets to purchase oral contraceptive pills every few months or visit a health centre to receive an injectable.
  • In many communities, it is men who travel to markets and women are not empowered to voice their contraceptive needs to men. Many women even face domestic violence if they show a desire to control their fertility.
  • Due to reluctance to compromise on sexual pleasure and perceptions that contraception is women's responsibility, 95 percent of Indian men do not use condoms

To address some of these issues, the Union Minister of Health and Family Welfare launched the Mission Parivar Vikas (MPV) to improve family planning services in 2016 in 145 High Fertility Districts spanning over seven high focus states (Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Rajasthan and Uttar Pradesh) which have Total Fertility Rate (TFR) of 3 per woman and above. They aimed to accelerate access to family planning choices based on information, reliable services and supplies. This introduced new contraceptive choices such as the contraceptive injection. ASHAs were given kits to distribute to newlywed couples which included oral contraceptive pills, condoms and a pregnancy test, and Saarthi mobile vans were introduced which offered family planning-related information and services at people's doorsteps. This program is welcome, but evaluations are required to assess how well implementation has occurred.

Adolescents are a particularly vulnerable group who require knowledge and access to contraceptives and safe abortion services to protect them from unwanted pregnancies. In the absence of comprehensive sexual education programs in public schools, adolescents lack awareness around reproductive health. Stigma against the use of contraception is also leading to risky sexual behaviour, such as practices of unsafe sex . Hence, early education and outreach to adolescents is required , with proper knowledge of contraceptive use. In October 2014, the government started the National Adolescent Health Programme, which set up 7500 Adolescent-friendly health clinics (AFHCs). These are village-based health clinics sensitive to adolescent needs. However, these are not enough to meet the demand. Adolescents are also unaware of these clinics, face an inability to independently travel to the centres, and have concerns over the side-effects of contraception use which prevents them from seeking more information .

Safe abortion is legal in India as per the Medical Termination of Pregnancy Act 1971. However, women are only allowed to terminate pregnancies if they have a reason and a doctor's approval. Up to 12 weeks, one doctor's referral is required, and between 12-20 weeks, the primary doctor must get approval from a second doctor. Abortion law does not give women autonomy and choice over their bodies - the choice rests with the doctor .

In March 2020, the new Medical Termination of Pregnancy (Amendment) Bill 2020 was introduced in the Lok Sabha by the Ministry of Health and Family Welfare. This proposed to increase the upper limit for termination of a pregnancy from 20 to 24 weeks under certain conditions, such as fetus anomalies or pregnancy as a result of incest or rape, with the approval of one registered medical practitioner (RMP) for up to 20 weeks of gestation. Although this reduces the administrative burden of the abortion process, the final decision to have the abortion is still with the doctor and not the woman.

Although safe abortions are an essential service that the state is responsible for providing, less than 25 percent of abortions take place in public health facilities . The majority of public health services in rural areas do not offer safe abortion services, as they are not sufficiently equipped and resourced .

Despite this law allowing women to have access to safe abortion under certain conditions, several challenges remain that are a barrier to access.

Due to lack of public messaging and education, women are often under the misconception that abortion is not a legal and safe option available to them, and are unaware of how and where to obtain safe abortion services .

  • As many women are never provided education, women lack awareness of the availability of pregnancy tests or do not have access to these due to cost barriers or inability to travel and purchase one themselves . In many areas, ASHA workers and ANMs provide free testing kits , but poor outreach to inform women of their availability means these often go unused
  • Abortion is still heavily stigmatised , and women are unable to discuss seeking an abortion with their families.
  • While medical abortion pills are available in markets, they require a prescription as per the MTP Act. This adds a barrier to access, especially if women are situated far from a doctor. In addition, most women do not have enough time to purchase the pill legally. Most women are not aware they are pregnant until 6 weeks of gestation at the earliest, but the pill is only licensed for use up to 9 weeks gestation. It is very difficult for many women to get access to a doctor, obtain a prescription and then purchase the abortion pill in a three-week time frame, particularly in rural areas.
  • Lack of freely available medical abortion pills in the public sector may reduce access to low-income groups. The price of the pill plus consultation may cost up to 1000 rupees .
  • As with contraceptive methods, many women are also unable to travel independently to markets and so men often purchase pills illegally for them. This may prevent women from seeking these pills due to the stigma against discussing the topic with males.
  • Even where women are able to travel, women often have trouble accessing transport to go to hospitals, especially in rural areas. There are also often cultural limitations on their mobility or access to finances to pay fares
  • Lack of trained staff and poor access to medical supplies and equipment prevent public health services from providing surgical abortion services. Hence, women are often forced to pay for safe abortions in private sector clinics. Private-sector medical abortions are expensive, costing anywhere between 500-10,000 rupees with all testing and user fees included . Women who cannot afford this are excluded.
  • In the public sector, women are often forced to accept a long-term contraceptive method after an abortion as clinics are sometimes incentivised at a district level to meet targets on the number of contraceptives provided . This is despite the national commitment to a target-free approach to contraceptive services in the National Population Policy 2000 .
  • Patients in public sector services also sometimes face harassment, particularly those from disadvantaged caste, religion or tribal groups if they are being managed by health staff from a different group .
  • Doctors may deny performing abortion services due to fears of getting accused of performing the abortion based on sex-detection, especially if the fetus happens to be a girl .

COVID-19 impacts on contraception and safe abortion services

Contraception and safe abortion services have been considered by the Ministry of Health and Family Welfare (MoHFW) as an essential health service during COVID-19 . However, COVID-19 has exacerbated the existing problems in accessing these services .

The provision of family planning services is not expected to reach normalcy until the end of 2020, if not later . Lockdowns, overburdening of the health system, shortage of healthcare personnel and fear of hospitals are all contributing to lower access to these services. It's estimated that an additional 2.95 million unintended pregnancies, 844,483 childbirths, 1.04 million unsafe abortions and 2,165 maternal deaths have occurred from the beginning of lockdown to September . For every 3 months from now, if current disruptions continue, an additional 2 million people may be unable to use contraceptives .

In addition, as economic hardships hit, the incidence of forced child marriage is increasing . Child marriage and engaging in sexual activities under the age of 18 years are illegal in India. Access to services must be continually provided to protect these girls from the harms of early pregnancy and childbirth.

The result of limited access to services in the second half of 2020 will be a surge in demand for contraceptive and safe abortion services at the beginning of 2021 . In order to ensure women's rights to bodily autonomy are maintained, it's essential that contraceptives and safe abortion services continue to be provided during and after the COVID-19 pandemic.

Effect of COVID-19 on access to contraceptives

It is expected that 63 million couples did not have access to contraceptives from March to September 2020 . This is being attributed to restricted mobility and lack of supply due to lockdowns, and fear of the virus preventing people from accessing over-the-counter OCPs, condoms, and emergency pills at local markets .

Due to the COVID-19 pandemic, the public health sector is shifting away from providing long-term contraceptives - as per the Centre's advisory, the public health system has stopped providing sterilisation and IUCDs . Public services are instead prioritising temporary contraceptives such as condoms and the oral contraceptive pill. Many private healthcare centres are also stopping the provision of permanent contraceptives and IUCDs to reduce the burden on health centres and focus on the current pandemic . This is limiting the choice and supply for women .

Young unmarried women, in particular, are less able to independently move around in the pandemic lockdown environment and access contraception. They are also unable to access confidential family planning counselling due to stigma both in the COVID-19 as women are at home more and are unable to travel and access support.

Access to abortion

COVID-19 is decreasing access to pregnancy tests. Many women are unable to confirm that they are pregnant if they are unable to visit a pharmacy due to movement restrictions, or if ASHA workers are unable to make their usual visits due to pandemic-related duties.

There are numerous reports of hospitals and health centres turning away non-COVID patients due to lack of equipment and personnel . This severely limits access to safe abortion services for women. Where patients are desperate for services, they are taking high-interest loans to access private health clinics at high costs . The provision of safe abortion services in the private sector have become more expensive as doctors must use more PPE and follow social distancing protocols . Some private hospitals are also implementing mandatory COVID-19 testing before surgery, also increasing the costs .

"We have had two women who showed up late after they decided to have an abortion. They were not able to get access to a test to confirm the pregnancy, they couldn't get transport to the hospital, answer not aware that abortion is being provided as an essential service. Due to that delay, they were over 10 weeks and medical abortion was no longer an option. Surgical abortion had to be provided to both." [Gynecologist experience]

Some women are also avoiding visiting hospitals for fear of infection . They are also unable to access transport in containment zones to visit hospitals to access the service, which is especially a problem in later-term pregnancies which often require multiple visits including counselling, surgery and post-operative care . Women who have tried to travel to hospitals have also been stopped by police, and they have not been able to verbally justify their travel due to stigma against speaking about women's issues .

"One patient told us about a police officer who beat her husband up because he was not ready to accept that she was pregnant because there was no obvious bump. The police officer refused to let them get into a cab/bus because he thought they were lying about wanting to go to the hospital." [Gynecologist experience]

The pandemic has brought with it an increase in domestic violence, as men are more likely to be at home. Pregnant women who do not want to continue their pregnancy are often unable to leave the house . They are also more likely to fall pregnant, given that domestic violence often occurs with sexual violence .

The lack of access to safe abortion services leaves women with some difficult choices - do they wait further in their pregnancy and opt for a second-trimester abortion? This is surgically more complicated, expensive, and requires greater postoperative care. Some may seek abortion from unsafe sources, and others may be forced to then carry their pregnancy to term.

Limited access to safe abortion services will increase the number of women attempting to use unsafe methods to terminate pregnancies such as overdosing on medicines or inserting a stick in the uterus, leading to an increase in the number of disability and deaths of women .
Recommendations
Solutions should seek not just to reduce the burden of the current pandemic, but ensure that access to safe abortions and contraceptives are generally pandemic proof in the future. Public health system funding must be increased to ensure that every woman has access to services despite their income level. Additional funding would ensure the following recommendations can be implemented.

Short-term solutions

The following recommendations can be implemented during the COVID-19 pandemic to improve access urgently.

1. Mainstreaming the use of telemedicine and helplines
Telemedicine can be used for the provision of remote services both during and after the pandemic to increase accessibility and ensure universal coverage. Telephone helplines can be used to screen women who are eligible for oral contraceptive pills or medical abortion. Contraceptive pills or medical abortion pills (for pregnancies up to 9 weeks) can then be delivered by post, through ASHA workers or through grassroots NGOs. The use of counselling over the phone has been shown to increase confidence and assurance in women struggling with preventing or dealing with an unwanted pregnancy . A similar model has been implemented in the UK successfully . The help-line can also be accessible for women with questions on administering and using the pills and provide support.

Where women have lower access to private phones, ASHA workers and Self-help groups can be leveraged to provide access to phones for women when required. Mobile vans can also be sent to communities to complete any examinations or scans required. These can be connected to doctors via telemedicine channels .

2. Family planning kits

Family planning kits which include condoms and oral contraceptive pills may be distributed to all households with adults over the age of 16, as has been done in some districts of Uttar Pradesh and Bihar . Some guidance should be given to communities on their use through ASHA's or men's meetings with a trained community leader. The provision of these kits should become ongoing after the pandemic.

3. Reducing the burden on ASHA workers through a COVID-19 -specific health workforce

For the COVID-19 period, a separate cadre of health workers should be trained to conduct COVID-19 -related activities such as contact tracing, to enable ASHAs and ANMs to continue their critical work relating to contraceptives and safe abortion service delivery . This may be done by engaging existing networks such as NGO and self-help group members who can be quickly accessed and involved as volunteers.

The opportunity to retrain and rebuild skills in the health sector through telemedicine, which has been big growth recently, can be leveraged to provide training and skilling in the provision of contraceptives to ASHAs, ANMs and other public sector health workers. Increasing the number of health workers able to administer contraceptives will improve their supply and accessibility. Training should cover how to sensitively deal with patients without increasing fear and perpetuating stigma.

4. Subsidies on private safe abortion services

For the COVID-19 and immediate post-pandemic period, private sector abortions may be subsidised by the government to ensure all women can afford them. Given many women would have missed on first-trimester abortions during the pandemic period, the demand for second-trimester abortions will increase. Women can receive guidance on how to access these services over telephone helplines.

Subsidies can be operationalised by either blanket subsidies to hospitals situated in poorer districts, or only to patients with BPL cards. State and national insurance schemes can also be expanded to cover safe abortion services.

Longer-term solutions
In addition to the continuation of telemedicine and family planning kit services, the following recommendations will strengthen contraceptive and safe abortion services overall to ensure the system is crisis-proof in the future and addresses previously existing gaps.
1. Community education and de-stigmatisation

A crucial first step is de-stigmatising the use of contraceptives and safe abortion services and making both men and women aware of the possibility of accessing these services. ASHA workers are a mode through which de-stigmatizing activities can occur, through one-on-one visits and women community meetings. This engagement should target not only younger women who may require these services, but also community elders such as mothers-in-law, to counter any stigma they may hold around abortion that would prevent them from supporting younger women in their households.

Men should also be sensitised to contraception and safe abortion services, as they often act as enablers to access where women have lower autonomy . Men's awareness activities can be run by specially trained men, such as engaging male multipurpose health workers, community leaders and local existing health workers.

Women also require more education on the types of contraceptives available, the possible side-effects of their use, recognising the early signs of pregnancy so they can access medical abortion services in time, and understanding how and where to access safe abortion services if needed. This will together reduce risks for women and reduce costs for the health system by decreasing the number of surgical second-trimester abortions.

Adolescents should also be targeted once they reach puberty to ensure they are aware of their own sexual health. This should include menstrual health, the changes the body goes through during puberty, and their rights to contraceptives and safe abortion services. Community-based peer educators can provide a link between the health system and the individual, and be a trusted source of confidential and personalised information for issues related to sexual health, such as helping individuals decide on a contraception method and helping them get access. These can be linked to AFHCs . NGOs already working in this space and existing self-help groups could be engaged to take up these roles, and reduce the burden on the public health system.

2. Increase the reach and variety of contraceptives available and expand the legal use of the medical abortion pill

The public health system should emphasise the provision of longer-term temporary methods rather than permanent methods, including IUCDs which last for 3-10 years and implants which last for three years. More options will ensure a variety of needs are met and will improve outreach and use of contraceptives overall. The reach of these contraceptives should also be ensured by providing adequate supplies and training to health workers in all parts of the country. Telemedicine can be leveraged to train remote health workers.

This approach mirrors countries like Bangladesh and Sri Lanka where unintended pregnancies have been gradually decreasing due to renewed focus on long-term temporary contraceptives and ensuring misconceptions around their use are being dispelled.

In addition, expanding the use of medical abortion pills beyond 9 weeks will improve accessibility and reduce the burden on health systems in providing surgical abortions. As per WHO recommendations, the use of the medical abortion pill should be made legal up until 32 weeks, with supportive services from trained health workers. This will ensure women can access abortion legally within a reasonable timeframe.

3. Mapping of current services and gaps

States should map the availability of service providers and facilities to assess the gaps to service provision. These lists can be developed into resources for the general public so women know where their closest service provider is located, and how to contact them. States can use these lists to invest in public health centres where contraceptive and abortion services are not available, such as through health worker training and equipment provision.

4. Remove legal barriers to accessing abortions and ensure the law enables women's right to choose

Currently, women do not have the right by law to terminate a pregnancy at will and require a doctor's referral. This process of acquiring a referral adds administrative burden, and also diminishes the autonomy women have over their bodies. In order to ensure better access to abortion services, the MTP Act should allow women to self-administer the medical abortion pill or seek a surgical abortion with trained support without the need for referral. This will streamline the safe abortion process and protect women's right to choose.

The Medical Termination of Pregnancy (Amendment) Bill 2020 reduces some administrative burden by proposing that pregnancies after 20 weeks, rather than 12 weeks, would need consultation from two registered Medical Professionals. However, a second opinion is not considered necessary by most medical doctors even with late-term abortion and may hinder and delay the process of seeking the abortion .

It should be noted that reducing the administration activities involved in the safe abortion process should not increase the incidence of sex-selective abortion. Similar protections as the present should remain such as banning doctors from revealing a fetus's sex . Sensitisation and de-stigmatising activities conducted with women about abortion should focus on the women's rights perspective, rather than the use of abortion to create an 'ideal family'. Safe abortion should be framed in public discourse as ensuring women's bodily autonomy.

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