How ‘Essential’ Abortion Services Are Inaccessible in the Lockdown

Millions of women and couples have been finding it impossible to access contraceptives and abortions on time.

8 min read
Over 24 million couples in India may not be able to access contraception during the COVID-19 lockdown.

(Sexual and Reproductive Health Awareness Day is held annually on 12 February. FIT is republishing this article in that light.)

A 19-year-old rape survivor in Mumbai found out she was pregnant right when India implemented its nationwide lockdown. She knew she had to get an abortion, but with no transport available and with many clinics shutting down their operations, she felt helpless and out of options.

“We went and picked her up and ensured she got the abortion at a public hospital. Forced sex is a critical issue in a lockdown and abortion services are required here and now,” Sangeeta Rege of the Centre for Enquiry into Health and Allied Themes (CEHAT), the NGO that intervened and arranged for the girl’s pass and travel, told Reuters.

It’s disturbing to think of the events that would have transpired had the NGO not stepped in. It’s even more disturbing to imagine the ordeal of thousands of women finding themselves in similar situations, with nowhere and nobody to go to for help.

India imposed a nationwide lockdown on 25 March in response to the COVID-19 pandemic. On 14 April, the government went ahead and declared abortion as an essential service. But women, since then, have been struggling.

For reasons ranging from the inability to travel to chemists and doctors, to the stigma surrounding sex and abortions, millions of couples have been finding it impossible to get birth control, contraceptives and abortions on time. For many women who are living at home with their parents during the lockdown, stepping out or telling someone may not be an option; which could leave them waiting for the restrictions to get lifted and for things to get back to ‘normal’ before they finally visit a doctor. The time-sensitive nature of abortion and the legal aspects surrounding it, however, could eventually end up denying the women this option altogether. This, in turn, could lead to an increase in unintended pregnancies, unsafe abortion practices and a spike in maternal mortality rates.

Over 24 Million Couples May Not be Able to Access Contraception

An analysis done by the Foundation for Reproductive Health Services (FRHS), India, found:

In the most likely scenario (where clinical family planning services operate at full capacity by September 2020 and sales of over-the-counter contraceptives are able to resume in a phased manner by the third week of May), it is estimated that 25.6 million couples would not have been able to access contraception during the period of the lockdown and the weeks leading up to complete normalcy (September 2020). In this scenario, there would be a loss of 6.9 lac sterilisation services, 9.7 lac intra-uterine contraceptive devices (IUCDs), 5.8 lac doses of ICs, 23.08 million cycles of oral contraceptive pills, 9.2 lac emergency contraceptive pills and 405.96 million condoms.

The loss of contraception methods from the best-case to the worst-case scenario.
The loss of contraception methods from the best-case to the worst-case scenario.
(Photo: Arnica Kala/FIT)

This is likely to result in an additional 2.38 million unintended pregnancies, 679,864 childbirths, 1.45 million abortions (including 834,042 unsafe abortions) and 1,743 maternal deaths. If the disruption continues for longer, the impact will worsen.

How ‘Essential’ Abortion Services Are Inaccessible in the Lockdown
(Photo: Arnica Kala/FIT)

“The health ministry has suspended sterilisations and IUCDs till further notice,” V.S Chandrashekar, CEO of FRHS, told FIT. It is important to note here that female sterilisation is the most preferred method of contraception in India. “Our organisation has been working closely with the government. From around 20 March, district officials in Bihar, UP and Rajasthan had started asking us to discontinue our family planning services. A large number of sterilisations are provided by the public sector, and other contraceptions like injectibles are relatively new here. Now in the past 1-1.5 months, there have been little or zero sterilisations.”

“Since most facilities are now focused on combatting COVID-19, we don’t see enough OPDs operating for other services. There has been a 50% drop or more in OPD clients walking in. Initially, even private and NGO facilities had discontinued services. It is only now that clinics have started opening up in response to calls and inquiries by clients.”
VS Chandrashekar

While availability is one aspect of the problem, the other (and common across rural and urban areas) is accessibility. Curbs on movement have made access to over the counter contraceptives, condoms, oral contraceptives and emergency contraceptive pills difficult.

Reports of couples being stopped on their way to the clinics, of pregnant women being forced to travel long distances for consultations, and of many of them not being able to go for their regular appointments because of no public transport, have been coming in from around the country.

“A lot of couples avoid going to the neighbourhood chemist shops to buy condoms or pills. They prefer going to pharmacies which are a little far to avoid any judgement and maintain anonymity. But now with the lockdown, traveling far is not possible, leaving many couples without contraception”, Chandrashekhar said.

Women Unable to Step Out; Resorting to Help Online

The stigma surrounding sexual activities complicates matters further, wherein women are unable to openly discuss their concerns or bring up the ‘uncomfortable’ subject with their families.

Hidden Pockets is a multilingual care line helping girls and women with their sexual and pregnancy queries and connecting them to non-judgemental counselors and abortion providers. In conversation with FIT, Jasmine George, founder of the platform, shares that there has been an exponential increase in panic calls and messages from girls from metropolitan and tier 2 cities. Many of them had been sexually active, but have now left their workplaces to come back home. Living with their parents, they don’t know where to go when they suspect they could be pregnant. “Getting so stressed out, in turn, can delay their periods, which only adds to their fear. With no other option, these women are depending on just their bodies to give them signs. And then there is the worry of the symptoms showing up, making it impossible to hide anything from their parents.”

“It’s just not possible for anyone to step out now. Because of the lockdown, your mobility is being tracked. Only one person from the family will go out and get the supplies, but an Ipill will hardly ever make it to the list.”
Jasmine George

Dr Suchitra Dalvie, a prominent gynaecologist and Coordinator for Asia Safe Abortion Partnership (ASAP), told FIT, “Every week, unmarried women have been calling me and saying that they could be pregnant, but there is no way or excuse to leave the house.”

Financial & Legal Deterrents to Abortion & Sexual Services

The chances of surgical abortions becoming costlier during the pandemic are high for multiple reasons. “Abortions are mostly accessed from the private sector. Some have had to shut down because of positive cases among their staff, others have had to scale down their facilities, and we have been hearing that many who remain open have increased the price charged for abortions,” Dr Suchitra Dalvie explains.

“A rise in the hospital’s input costs in terms of holding additional screenings for the virus, implementing social distancing, and buying Personal Protective Equipment (PPE) for the health workers have increased their expenses, which could make them charge higher for surgical abortions. The private sector is also facing financial issues because of low profits and low admissions for other conditions and illnesses,” she adds.

Chandrashekhar speaks about the fact that many private hospitals have been insisting that their patients get tested for COVID-19. This would add another Rs 4500 to people's expenses, making them avoid visits and consultations altogether.

“People are losing their jobs and essentially becoming poorer, while the cost of essential services is going up. Given all this, there has been a clear downward trend in accessibility of services.”
Dr Suchitra Dalvie

Adding to this is the Medical Termination of Pregnancy Act (MTP) of India. Women in the country can access medical abortion pills only up to 9 weeks of pregnancy (with a prescription). This means that those who are unable to access the pills during the lockdown, may run out of the option by the time the country opens up, leaving them with only two alternatives: surgical abortion (only after availing the consent of two medical practitioners) or resorting to unsafe abortion practices. Going for surgery while keeping one’s anonymity maintained, having enough financial resources to get it done, and overcoming the fear of going to the hospital in a pandemic - can all make the choice extremely difficult.

But the problem doesn’t end here. The limit for getting the surgical abortion is up to 20 weeks into the pregnancy, after which the case would have to be taken up to the court, where permission is only granted based on certain inherently ‘conservative’ considerations, as FIT had earlier reported. If women are unable to get the surgery done on time, they would have no option but to take this legal road, which can be draining and slow, giving up on valuable time.

Dr Nupur Gupta, Director, Obstetrics & Gynaecology, at Fortis Gurugram, tells me how this can be problematic medically. “In a lot of pregnancy cases, fetal abnormalities are known of only later on during the pregnancy. Many of these can only be detected in the level two ultrasound, which isn’t offered at all places. Several ultrasound centres are shut right now, and at other places, competent doctors may not be available. Now if for these reasons, or for the fear of contracting the infection from hospitals, couples decide to delay the ultrasound, they may only get to know about it later. This could be past the 20-week limit.”

“I have two such patients. They didn’t get the ultrasound done on time, and later found out about the abnormality. Now they will have to go to court and apply for a special law. During such times. courts will have to consider extending the termination limit.” 
Dr Nupur Gupta

The solution to this, Dr Gupta says, is communicating with the patients and keeping them well informed about timely visits and appointments. “We can’t lose track of them. Online consultations are helping us stay in touch. We need to tell them if it is okay to wait, and what all is at stake.”


Implications: Unsafe Abortions, Unintended Pregnancies & More

The lockdown has particularly been affecting women in more ways than one. For those in abusive relationships, domestic violence is on the rise, making the possibility of forced sex extremely worrying. Considering all this and the multiple reasons making contraception and abortion inaccessible, unintended pregnancies are expected to spike.

Moreover, couples who used to come for regular contraceptive counseling and family planning consultations, are also not visiting doctors right now. Dr Nupur Gupta says, “Even regular options such as copper T insertion have now come down significantly. People are not coming in for counseling for the use of contraception, while still being sexually active. All of this will contribute to more women becoming pregnant.”

These factors are almost directly linked to women either opting for unsafe abortions (which is inevitably harmful) or going ahead with their pregnancies and giving birth. Chandrashekhar expects to see a rise in abortion requests when the lockdown is lifted, “Many of these will be second-trimester abortions, facilities for which are anyway limited.”

Since there will also be several women who won’t be able to terminate their pregnancies in time, childbirths are also expected to increase.

“Once things return to normalcy, it is possible that some of the lost sales/distribution can be made up in the coming months, but the health impact of millions of couples not being able to use their preferred method of contraception is unlikely to be made up. If the situation takes a longer time to normalise, the adverse impact would be far more severe,” the FRHS said in a statement.

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