Despite victories, abortion still stigmatized, regulated in India

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When Sakshi Bhatt, a Delhi-based journalist, required an abortion last June after an unexpected pregnancy, she assumed that she would be able to obtain safe medical care without much trouble. But Ms. Bhatt’s experience left her distressed and emotionally scarred.

“When the doctors realized I was not married, they were not supportive at all, and kept making judgmental comments like, ‘You are a girl, you should have been more careful,’” said Ms. Bhatt, who works at Outlook, a news magazine.

Her scans revealed an ectopic pregnancy, which can be dangerous if not treated properly. She was admitted to a leading public hospital, where she found little comfort.

“The doctors pressured me to call my parents. They made me feel like a criminal. Five months after, I still have sleepless nights. I am in survival mode and undergoing therapy.”

Ms. Bhatt is not alone in being stigmatized for needing an abortion, a procedure that is strictly regulated in India. Fear of prejudice and loss of privacy are the chief reasons why millions of women resort to illegal abortions at unlicensed facilities, or turn to unsupervised over-the-counter pills. But a recent landmark Supreme Court ruling declared that all women, including those who are unmarried or survivors of marital rape, are entitled to safe and legal abortion. Rights groups and gender health experts see it as a major win that could reduce the number of unsafe procedures.

“It is an important and welcome step toward visibilizing, advancing and recognizing abortion as a right,” said Adsa Fatima, a training and research co-ordinator at Sama Resource Group for Women and Health.

But the court’s ruling is also a reminder that abortion remains a divisive, complicated issue in India. For starters, abortion is still a criminal offence under the Indian Penal Code even though it is has been legal – with conditions – since 1971. That’s when the Medical Termination of Pregnancy Act was introduced, allowing abortions up to 20 weeks for married women in certain situations – including failure of contraception, threat to a woman’s life, abnormalities of the fetus and in some cases of sexual violence – and only if two doctors signed off. Unmarried women faced even tighter restrictions.

Significant amendments expanded the ambit of the MTP Act last year. The changes made abortion more accessible to unmarried women, increased the upper gestation limit to 24 weeks, strengthened confidentiality and reduced the required doctor sign-off to one. The Supreme Court’s September ruling took it a step further, recognizing marital assault as a legitimate reason, and declaring that prohibiting a woman from having an abortion based on her marital status was unconstitutional.

These changes have made it easier to process abortions, particularly emergency, high-risk ones, said Tripti Sharan, a Delhi-based gynecologist and obstetrician.

Still, the new Supreme Court ruling does not change the fact that women in India do not have complete autonomy over their reproductive rights. And structural and social barriers, such as a patriarchal society, stigma and discrimination, continue to exist. (One of the reasons abortion remains criminalized is for fear of it being misused to abort female fetuses, a practice prevalent in India owing to a cultural preference for male children.)

There are also glaring gaps when it comes to access: Too few medical practitioners are licensed to perform abortions in India, contributing to a dearth of legal abortion facilities.

“The amendments to the law will take time to trickle down. Literacy around abortion is very low. In smaller cities and towns, most people still don’t know abortions are legal,” said Jasmine George, founder of Hidden Pockets Collective, a reproductive health awareness initiative that runs an abortion helpline. Many women still travel to another city to maintain privacy because of the stigma attached to it, she added.

These barriers are even more acute outside of cities. “In rural areas, women do not have reproductive rights, teenage pregnancy is high and there is a preference of traditional systems of neighbourhood quacks,” Dr. Sharan said, referring to unqualified, unlicensed medical service providers.

Only 10 to 30 per cent of health facilities provide abortion services in an average rural district, said Sharad Iyengar, chief executive at Action Research and Training for Health Society, a non-profit organization based in Rajasthan that provides medical abortions. The hope is that the new ruling will increase those numbers.

“The major benefit of the amendments is that this has liberalized the training of more doctors in abortion services,” he said. “We need to urgently ramp up the pool of abortion providers.”

In cities, meanwhile, unlicensed facilities thrive, as they remain poorly regulated. Close to eight women die each day as the result of an unsafe abortion in India, according to the State of the World Population Report 2022 by the United Nations Population Fund (UNFPA), making them the country’s third leading cause of maternal mortality in the country. Sixty-seven per cent of abortions in India are deemed unsafe.

Medical experts say the Supreme Court ruling does not go far enough to address the issue of illegal abortion centres or pharmacies selling abortion pills without a prescriptions. “We get cases of botched abortions every few days,” Dr. Sharan said.

Even where access is not a problem, women fear going to a health facility because of the conservative attitudes that persist, said Somya Gupta, a Gurugram-based gynecologist. Medical practitioners still yield a lot of power, as the procedure can only be done with a doctor’s approval.

“It leaves millions of women at the mercy of medical practitioners and the state,” said Vinitha Jayaprakasan, programme co-ordinator for abortion rights and reproductive justice at YP Foundation. “It pushes young people to resort to other means to access abortions. Medical practitioners operate from a moral and patriarchal lens. The health care system needs to realign and be more sensitive.”

One solution, Dr. Gupta said, would be to make it easier for women to obtain abortion pills legally and use them safely. “Abortion in India is overregulated. Opening up telemedicine for early abortion services, as the U.K. has done, would help.”

Abortion-rights campaigners believe the court’s ruling, despite its setbacks, has set the right tone for progress; now, stakeholders need to push for better implementation.

With discourse around abortion rights growing not just in India, but around the world, Ms. Fatima has felt the winds of change, and noticed a more concerted effort to widen abortion access and awareness.

“If it is not accessible to all, then what good is it? Abortion should not be a privilege of a few who can afford it,” she said. “Let us bring those marginalized to the centre of the conversation. With the judgment, we have something to hold on to … and hope for broader and more comprehensive interpretations of the law.”