The Worrying Disappearance of Medical Abortion Drugs in India
More than 80% of all abortions in India are performed using drugs. What happens when this option is taken away?
(Sexual and Reproductive Health Awareness Day is held annually on 12 February. FIT is republishing this article in that light.)
India legalized abortions in 1971 with the Medical Termination of Pregnancy (MTP) Act — becoming one of the first few countries to give women the option to abort even in situations that are not life-threatening.
Undoubtedly, the law is among the more progressive abortion laws that exist in the world. Advances in medicine and technology have opened doors to safer and more convenient options, such as medical abortion drugs (mifepristone and misoprostol) that can be used within ten weeks of pregnancy.
But the struggle for access to safe abortion in India is far from over — with expected but often unprecedented obstacles in the form of social and cultural backlash, overregulation, unawareness and legal loose ends.
The latest of these is rather scary, with the potential of taking us back almost a decade in the progress we’ve made in making abortions accessible, convenient and simpler. Let’s take a closer look.
Pratigya Campaign for Gender Equality and Safe Abortion recently commissioned a study with Centre for Media Studies on Availability of Medical Abortion (MA) drugs in the urban markets of four Indian states (Bihar, Maharashtra, Rajasthan and Uttar Pradesh). This study covered 1008 retail chemists to assess the availability of MA drugs in these states; and to understand the awareness levels and attitudes of the chemists stocking and selling the drugs. Here are the findings:
Why Is Medical Abortion (MA) a Big Deal?
The Drug Controller General of India in 2002 approved the use of a combination of Mifepristone with Misoprostol tablets for early abortion. Since then, MA has emerged as a safe and simpler method for women who may have otherwise faced barriers in accessing safe abortion care.
FIT speaks with V.S Chandrashekar, Chief Executive Officer, Foundation for Reproductive Health Services (FRHS) India and Rupsa Mallik, Director, Programs and Innovation, CREA — both CAG members of the Pratigya Campaign, to decode the findings and understand how the situation could be rectified.
“MA has been found to be the most preferred method of abortion. It is non-invasive, safe, accessible, cheaper, convenient, and ensures more confidentiality. With its introduction, a number of pharmaceutical companies started launching MA combipacks, bringing down the number of unsafe abortion procedures. That’s why, the non-availability of these drugs is a grave concern.”V.S. Chandrashekhar, CEO, FHRS India
The Cost of Conflating Two Separate Laws
Overregulation of medical abortion in the form of frequent raids by drug inspectors, requirement of maintaining records and prescriptions, and legal barriers — have all been cited as reasons for not stocking the drugs in the retail shops. But why this overregulation?
A logical fallacy would explain it.
India has been fighting many battles, two of which are the skewed sex ratio and unsafe abortions (leading to a higher maternal mortality rate). Naturally, exclusive laws exist for both — Pre-Conception and Pre-Natal Diagnostics Techniques (PCPNDT) Act for the former and MTP Act for the latter.
Now, further decline in the child sex ratio led to rigorous enforcement of the PCPNDT Act, and abortions started coming under undue scrutiny.
“A common misunderstanding that all abortions are sex-selective along with a low level of awareness about the MTP has resulted in unnecessary raids and crackdowns on provider sites and chemist shops. Fear and apprehension of increased scrutiny has resulted in non-stocking as the chemists don’t want to face legal hurdles.”The report
But the two laws are mutually exclusive. First, all abortions are not sex-selective, and second, abortions alone cannot be considered responsible for the poor sex ratio.
Rupsa Mallik highlights an obvious, yet unconsidered fact,
“MA is approved only up to ten weeks. But it takes 12-14 weeks for ultrasound to be able to disclose the gender. So how do the two relate in any way? There is obviously no causal link. Since it is hard to regulate ultrasounds (because they take place in private settings), abortion becomes the most apparent and on-the-face act to control. But abortion is not one unit; it is comprised of many methods, some of which (like MA drugs) are not even remotely related to sex-selection. That needs to be pointed.”Rupsa Mallik, Director, Progams and Innovation, CREA
This overregulation bleeds into the minds of these chemists in different forms, affecting their awareness and knowledge about medical abortions. The unnecessary checks often make them doubt the very legality of abortions (43 percent believe they are illegal). Moreover, many of those who do keep a stock are not aware of the way the drugs need to be administered (53 percent).
“None of the other schedule H drugs are regulated this way. It’s assumed that regulating MA is regulating sex-selective abortions. Singling it out and demanding records, makes it seem like the drugs are being treated as something very different. This creates a chilling affect among the chemists, which manifests itself in different ways — most apparent being not stocking them in their shops.”V.S. Chandrashekhar, CEO, FHRS India
Expanding Provider Base
The MPT Act, as pointed out by VS Chandrashekhar, was a liberal one at the time it was introduced. Abortion, the way it existed, required skill and carried potential risks if not performed properly — and so it made sense to limit who could provide it. But over the years, technology has improved and the Indian landscape has changed dramatically.
“It is no longer a ‘procedure’. With medical abortion coming into the picture, it’s more about awareness and knowledge than about skill. It’s as simple as someone undergoing a heavy menstrual period. So clearly, the act needs to be updated.”VS Chandrashekhar
In fact, the World Health Organisation recommends that the task of medical abortions in first trimester could also be provided with trained ayurveda, unani, homeopathy doctors and registered nurses.
However, India’s MTP Act allows only obstetricians/gynaecologists and physicians trained in surgical abortions to prescribe medical abortion drugs.
India has over 42.3 lack providers who meet WHO requirements for abortion care givers, but currently, only 65000 providers exist.
So expanding provider base and de-linking sex-ratio and medical abortion are primary recommendations of the study.
Improving knowledge of chemists on MA and abortions comes next. Chemists often do more than just sell the drugs. They are the point of contact for many women and potential sources of information. Any lack of awareness among them could be a cause for misinformation to be disseminated. For instance, many chemists in the study thought bleeding is a side-effect of the drugs, not knowing that it’s actually part of the abortion process.
The ultimate objective is to raise awareness among women. They should know all their options and risks involved, those options should be made available to them, and they should be able to take calls for themselves. The study also recommends working closely with pharma companies to ensure clearer communication. For instance, bigger fonts and local languages could be used on the comipacks.
Let Women Decide
Rupsa Mallik points towards the fact that women related health issues are often regulated and scrutinized unduly — because of an underlying lack of trust in their rationality. It is simply assumed that providing them with a safer and easier option of abortion will lead to multiple abortions and complications.
“Medical abortion has transformed India, yet the country is struggling to reduce maternal mortality. With sex-selection or multiple abortions given as excuses, women’s lives are put at danger and these issues are not resolved either. So what are we achieving? And even if women opt for more number of abortions, it has been proven that medical abortion is safe and does not have any major complications if administered properly.”Rupsa Mallik
She adds, “In the study, we even saw that most women are either visiting doctors for follow-ups, or are not experiencing any complications at all. So we need to trust a woman’s wisdom in taking decisions for herself. She will do what is best for her.”
The point being made is simple and clear. The introduction of medical drugs has impacted women healthcare positively, but overregulation (leading to disappearance from the markets) will just turn the clock back and take us to a time when women were forced to resort to procedures that held high risks and complications.
“Twenty years ago, abortion complications were horrendous. We don’t want that to repeat. We are denying the women a safe option by not making these drugs available. What recourse will they have?”VS Chandrashekhar
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