A proposed law would allow midwives and other mid-level providers to perform abortions and potentially save lives, but members of the medical establishment are skeptical.
Geeta doesn’t remember exactly where it was that a girl she knew threw away her baby. She’s also not sure if the mother of a childhood friend went to jail or not after she tossed two infants, her ninth and 10th daughters, into the canal. But she does remember the day the woman in the slum stuck the handle of a stove-cleaning brush into her vagina, through her cervix, and into her uterus in an attempt to self-induce an abortion.
“Seven or eight years ago, a woman here inserted a metal bar to clean the stove to start bleeding,” Geeta says through a translator. As far as Geeta knows, abortion is illegal, and she’s never seen anyone go to the local hospital for an abortion. But the woman with the stove-cleaning rod, Geeta says, “That I saw.”
Walking from the densely populated urban slum where Geeta lives in Pune, a South Indian city two hours from Mumbai, to the doors of YCM Hospital, the large teaching facility across the street, takes about two minutes, across a hectic road where maniacal drivers dodge each other, food stalls hawk all manner of fried local fare, and you can buy anything from underwear to SIM cards. But while the physical gap between the hospital and the slum is a small one, the space between what the hospital provides and what women in the slum see couldn’t be wider — especially when it comes to abortion.
As Geeta tells the story of the metal bar, a dozen young doctors in the YCM hospital are learning how to safely terminate pregnancies. That same day, a handful of women are undergoing abortion procedures, which are paid for by the Indian government if a woman is poor. Geeta and a dozen of her neighbors had no idea that they could terminate a pregnancy across the street for free or that the procedure has been legal here since 1971.
Even though abortion laws are liberal in India, with elective procedures largely permitted up to 20 weeks of pregnancy and no powerful anti-abortion movement influencing legislation, illegal and sometimes unsafe abortion is also rampant, and remains a driver of maternal death and injury. High rates of illiteracy, limited access to information, stigma around the procedure, laws dictating that only doctors can perform abortions, and a highly publicized campaign against sex-selective abortion all contribute to the general assumption that terminating a pregnancy isn’t an option for many women who need it. Instead, Geeta and other women in the Pune slum say, there are home remedies: Eat papaya, then banana, then black coffee, then something hot if your period is delayed by a few days; maybe find a pharmacist who will give you a pill.
For Geeta and her neighbors, reproductive health comes primarily from auxiliary nurse midwives, or ANMs, and ASHAs, accredited social health activists (more or less volunteer community health workers), who are part of the fabric of local communities, and serve as trusted sources of information and care — ANMs vaccinate babies and check to ensure pregnancies are healthy, and ASHAs dole out birth control pills and condoms. And in some ways, the women in the urban slum are lucky, as far as health care goes — at least they have the hospital for serious issues. For women in India’s many rural villages, hospitals are often far away and there may not even be a doctor working in the closest one, and so nurses and midwives are the ones who deliver babies, and provide nearly all other forms of basic medical assistance and reproductive care. But there’s one exception: Abortion.
If reproductive health advocates have their way, though, that may soon change. The Indian government is considering a new law that would allow mid-level providers, including ANMs, to dispense medication abortion, or “abortion pills,” to the women they serve. A final decision could be made in Parliament as early as this spring.
“In my experience, the biggest barrier to safe abortion access in India is the acute lack of physicians in rural and hard-to-reach areas,” says Vinoj Manning, executive director of the Ipas Development Foundation, an abortion rights group in India. “The new law will enable the public health system to train, equip, and mobilize a significantly large number of alternate abortion providers in geographies where currently there are no doctors.”
But the proposal is not without its detractors. The central question is whether training midwives to provide early abortions in non-medical settings would be beneficial to women’s health or a threat to it.
Down one of the slender alleyways in the same Pune slum where Geeta lives, a child’s dark brown eyes widen as he watches a needle-wielding woman squeeze his arm and prepare to stick him. He buries his face in his mother’s chest; she strokes his head, and then the nurse, cooing, slides the needle in. There’s no air conditioning or electricity, and the room is packed with a dozen mothers, their children, and visiting nurse midwives. It’s immunization day in this neighborhood, and a handful of ANMs are systematically vaccinating a line of children against diseases like polio and measles. It’s these same women who, someday soon, could be front-line abortion providers to India’s most vulnerable communities.
Allowing ANMs to dispense abortion pills “would make it more accessible,” one of the midwives says through a translator after the mothers and children have left. The other midwives jump in, with most agreeing that, yes, medical abortion would be a helpful part of their health care arsenal. Then a doctor, visiting the vaccination site with me, speaks. How, she asks, will the midwives accurately determine the date of a pregnant woman’s last menstrual period and, by extension, the age of her pregnancy? The room falls momentary silent. A few of the midwives acknowledge that they worry about complications.
A national version of this same debate is taking place in India’s medical community now. To many midwives and reproductive health advocates, the new law is a no-brainer: As the primary point of contact between so many women and the formal health system, ANMs should have abortion pills at their disposal.
“What the Indian government is considering is standard practice in many public health systems of the world,” Ipas’s Manning says. “Today, nurses and other non-physician cadre provide early abortion services in around 17 countries. To put this data in perspective, in more than 30 percent of the countries where the abortion law is [as] liberal as the Indian one, they rely on non-physicians to manage abortion services.”
Yet the law faces staunch opposition here, and the loudest opposing voices aren’t right-to-life activists — they’re doctors, many of them abortion providers themselves.
“The most important threats [to Indian women’s health] are morbidity and mortality related to unsafe abortion services,” says Dr. Salve Pavan Vasantrao, a medical officer of health at YCM Hospital in Pune. But giving paramedical providers, like midwives, abortion pills to dispense to women directly, “This is a very tricky issue,” he says.
While there isn’t great data, the most thorough estimates suggest that the Indian abortion rate hovers somewhere around 6.4 million a year — that would be 26 abortions for every 1,000 women of reproductive age every year. It is also 10 times the number of abortions reported by the Indian Ministry of Health, suggesting that many procedures are taking place clandestinely (many also are likely left out of the Health Ministry’s data because of poor reporting and data collection in hospitals). Still other studies have found abortion rates as high as 70 abortions for every 1,000 Indian women. And according to Ipas, between 3 and 4 million women in India have unsafe abortions every year. Nine of them die every day.
A variety of cultural, logistical and financial problems make Indian women hesitant to come to hospitals for abortions. Abortion here may be legal, but, like in many places around the world, it remains heavily stigmatized, especially for unmarried women, who aren’t supposed to be having sex in the first place. And married women, especially in the lower classes, have few social rights, needing the approval of their husbands and often mothers-in-law to make any reproductive decisions, including using contraception or seeking an abortion.
“Like all others, we also have a patriarchal society, a male-dominated society,” Vasantrao says. “If a girl or a woman becomes pregnant, it is not her decision to continue the pregnancy or not.”
Even if she gets that permission to end the pregnancy, her options are mostly bad ones. She can go to the local hospital, which for women in rural areas may be far away and may not have anesthesia, consistent electricity, or a doctor at all, and where she’s almost guaranteed to run into someone she knows. She can go to a larger government hospital, which may be far and expensive to get to if she lives rurally and where she may see a friend or neighbor if she lives nearby. She can go to a private facility, which charges more than many Indian women can afford. She can find a friendly pharmacist willing to sell her a pill under-the-counter but who is unlikely to know the exact protocol for taking it, or she can seek out an informal or self-taught abortionist.
“Abortion services, they’re hugely costly,” Vasantrao says. “For two reasons: The cost of the service and the cost of the secrecy. The secrets cost. If she wants to go to a private practitioner, it costs something. That is a limiting factor. Then another option is to go to quacks, untrained practitioners, which is a huge threat to her life and limb.”
Complicating matters is that, like Geeta, many women don’t even know abortion is legal to begin with. A third of women in India are illiterate, and little information about abortion legality and safety filters down to women in the slums and in rural villages. The one exception is the illegality of sex selection, a topic on which the government launched a wide-reaching and highly effective information campaign in an effort to stop families from aborting female fetuses. Ipas has small-scale programs to inform women in several Pune slums of their safe, legal abortion options — they haven’t gotten to Geeta’s slum yet — and they also train groups of ANMs and ASHAs to refer women to safe abortion providers. But many ANMs also report that stigma around abortion means women don’t come to them asking about in-hospital procedures. And Ipas is just one nonprofit in a country of more than a billion people, without the capacity to train all of India’s more than 1 million nurses and midwives – only some of whom are formal ANMs, while others are traditional, unregulated providers. In contrast to the government’s intensive campaign against sex-selective abortion, no mass government campaign exists to let women know where they can get a safe, legal abortion.
The YCM Hospital is one of the best public hospitals in the region, and here, women in Pune and the surrounding areas who can’t afford to go to private facilities can come for free or cheap health care. That includes abortion services — if women know they exist. But safe abortion, even in hospitals, is not universal in India, which is why Ipas is training new doctors on how to terminate pregnancies, so they can offer the procedure in their own facilities, often in underserved rural areas.
“I see many patients come in for abortions, but we don’t have anyone to do it,” says Dr. Ganesh Sonavane, an abortion trainee who works in an understaffed primary health center outside of Pune. “I’ve also seen a lot of patients who come in shock from septic abortion.”
Nearly every ob-gyn in India, it seems, has a heartbreaking story of septic abortion — or a litany of them. One described a 14-year-old girl who came to the hospital with sticks coming out of her cervix and vagina. Others mention women who bled out for days before finally seeking help. Two years ago, says Dr. Varsha Dange, a women’s health officer at YCM Hospital, a woman came in after taking a medication abortion pill, having severe bleeding, and going to a local hospital without adequately trained abortion providers only to have one of them accidentally perforate her uterus in trying to complete the abortion.
“By the time she was brought to our hospital, she was in severe sepsis, and it was too late,” Dange says. “Such a simple procedure as an abortion cost her her life.”
That’s why, many doctors say, they can’t support legislation that would let midwives dispense abortion pills: They’ve seen what happens when women take those pills incorrectly. And yet, despite the horror stories, they also say that widespread access to medication abortion has made illegal abortion in India — and much of the rest of the world — safer than ever.
“It is a boon for the women because they don’t have to get to a maternal health facility, that is one thing,” Dange says. “The second thing is it is very easy, and the confidentiality has been mentioned, because then nobody else will look upon her or ask her, ‘Why have you been to the health facility? Did you undergo any surgery?'”
Additionally, Dange says, the pills are effective: She says even unregulated early use results in a complete abortion in up to 90 percent of cases. “Down the line, this has made abortions much safer,” she says. “It is near-safe abortion.”
But she remains skeptical of the proposed legislation, saying unsupervised use of the pills poses problems. The hospital still gets a lot of women with incomplete abortions, who took the pills after the recommended cap of seven weeks of pregnancy or only took the first pill, which stops the fetus from growing, but not the second, which fully expels it. That poses risks to their health and, sometimes, to their lives.
“The bottom line is this,” Dange says. “You need to have a supervised regimen and the proper treatment, including counseling of the patients.”
One question is whether it’s possible to adequately train midwives to appropriately dispense abortion pills. The proposed law wouldn’t just hand out the pills to every ANM; it would require that they receive formal training first. But some doctors say that isn’t a fix. In many countries, midwives are highly trained medical professionals and skilled birth attendants; in India, with its relatively decentralized health system, that’s not necessarily the case across the board, and doctors worry that even a training won’t be enough to give ANMs the skills necessary to offer appropriate treatment and adequately deal with complications.
Dr. Reena Mittal, a gynecologist and abortion provider who works in the north Indian city of Udaipur at another hospital where Ipas conducts safe abortion trainings for doctors, says her answer to whether midwives should be able to dispense abortion pills is “a big no. Because misuse will be rampant with them.”
Midwives in other countries, she says, are better-educated than those in India. “Knowledge is definitely low [in India],” she says. “And even if you educate them, they don’t know the complications of this procedure.”
Still, reproductive health experts point out that despite varying skill sets, many midwives are already providing care far more complex than early abortion. Abortion is simpler and safer than it’s ever been, and with some training, they say, there’s no reason why midwives couldn’t provide abortions for women across the country.
“According to data from CDC, the risk of death from pregnancy and childbirth is 14 times higher than with abortion,” says Ipas’s Manning. “When most institutional deliveries in India are conducted by nurses and midwifes, why can they not perform non-surgical, medical abortion after they go through a training program, as is being envisaged by the government?”
Back in the Pune slum, the midwives are gathering their supplies — vaccines, gauze, Band-Aids, needles — and making careful marks in detailed spreadsheets, recording who had which shot, and noting on a calendar when each child will need the next one. They’ve been trained to do this and have been given the appropriate resources from the government to build their professional capacities and skill sets in order do their jobs effectively. Given similar tools, the midwives say — training, information, maybe a system of referring patients to the nearby hospital if there are complications — they are also perfectly capable of dispensing abortion pills.
“If the woman doesn’t tell me about [her last menstrual period] or gestation properly, it might lead to certain complications,” one midwife in Pune says. “But if we’re given the proper training and capacity-building, we can provide these services.”
She can’t talk for long. The day is almost over, and she has a list of women and their babies to check on.
Jill Filipovic is a 2015 International Reporting Project fellow in India.