New Delhi: In the first three months of the COVID-19 lockdown, March 25 to June 24, 2020, 47% of the estimated 3.9 million abortions that would have likely taken place in India in this span under normal circumstances were possibly compromised. This means that 1.85 million Indian women could not terminate an unwanted pregnancy, concluded a May 2020 modelling study conducted by the Ipas Development Foundation (IDF), India, a non-profit dedicated to preventing and managing unwanted pregnancies. Of these 1.85 million women, 80% or 1.5 million compromised abortions were due to the lack of availability of medical abortion drugs at pharmacy stores, the study found.
The estimation builds on data from telephone surveys of 509 public-sector facilities across eight states, 52 private-sector providers, expert opinion of members of the Federation of Obstetric and Gynaecological Societies of India (FOGSI), sales data on medical abortion drugs, and trend estimation by pharmaceutical industry experts.
Another 20%, or nearly 370,000 abortions, were compromised due to reduced access to facilities--16% due to reduced access to private health facilities and 4% to public health facilities. Of the estimated 15.6 million abortions that happen in India annually, 73% are through drugs accessed outside facilities, 16% in private health facilities, 6% in public health facilities and 5% through traditional unsafe methods, according to a 2015 study published in The Lancet.
Lack of access to contraception is likely to result in millions of unintended pregnancies, unsafe abortions and maternal deaths and the government’s family planning programme is also likely to take an up-to-20% hit, IndiaSpend had reported in May 2020.
Millions of women would have thereby been forced to either continue with an unwanted pregnancy or undergo a late-term or unsafe abortion. It is hence crucial to plan and ensure that sexual and reproductive health is embedded into the country’s disaster management plan, Vinoj Manning, the chief executive officer of IDF of India, tells IndiaSpend in this interview.
Manning is a member of numerous national task forces on contraception and abortion and part of a World Health Organization expert group tasked with sharing guidelines for safe abortion. He has a post-graduate diploma in rural management and an MBA-plus leadership certificate from the School of Business, Portland State University, US.
How did the lockdown restrict women’s access to their choice of contraceptives, an essential?
In many ways, factors affecting women’s access to contraceptives during the lockdown were similar to that of abortion:
- Public health facilities were converted to COVID-19 care centres, limiting the availability of sexual and reproductive health (SRH) services
- Clinical staff occupied with the COVID-19 response may not have had time to provide services or may have lacked personal protective equipment to provide services safely
- Private health facilities were either closed or limited their service provision due to provider unavailability, inadequate protective gear, or lack of mandatory COVID-19 testing arrangements
- Supply chain disruptions limited availability of contraceptives and stock-outs of many contraceptive methods
- Suspension of public transport facilities and curbs on movement restricted women’s mobility.
In addition, some specific reasons include:
- Temporary suspension of the provision of sterilisations and IUCDs in line with the Ministry of Health and Family Welfare’s advisory till about mid-May, when revised guidelines were released. This meant that women were unable to use their preferred method of contraception especially if they needed long-term contraception.
- Involvement of ASHA workers in COVID-related surveillance work impacted the community-level distribution of contraceptives.
- Women refrained from visiting health facilities due to fear of COVID-19 exposure.
What are the likely choices for a woman who could not access contraception and discovers her pregnancy during the lockdown?
Possible choices for such a woman include:
- continuation of her pregnancy even though it may be unplanned or unintended;
- attempting an abortion during the lockdown through safe or unsafe methods (there are chances she may attempt medical abortion pills from a chemist outlet or visit a backstreet provider); or
- waiting until the lockdown restrictions are relaxed and then undergo most probably a second-trimester abortion in a health facility (since it is likely that due to the lockdown she may have crossed the 12-week gestation limit of medical abortion).
For women, what are the long- and short-term impacts of being denied contraceptives?
Women who are unable to access contraceptives are likely to make decisions that may not be as per their preference--whether it be the continuation of their unintended pregnancy or second trimester or unsafe abortion. All of these are likely to have profound consequences for their overall health and well-being, including physical health since the unintended pregnancy may not ensure adequate spacing with the previous childbirth, as well as mental health (beyond the lockdown’s own impact). Unsafe abortion may lead to morbidities with long-term consequences on health and in the worst case, result in mortality among women.
There would be financial implications as she/her family may have to spend significantly more in seeking an abortion or in continuing with the pregnancy. In an environment of job loss and economic instability due to COVID-19, this could be detrimental to the well-being of the entire family, including young children, as nutrition, family dynamics etc are likely to be impacted.
Unsafe abortions are the third largest cause of maternal deaths in India. Did these rise during the lockdown?
As per the World Health Organization, abortions are:
- Safe when they are done with a method recommended by WHO and if the person providing or supporting the abortion is trained. Such abortions can be done using tablets (medical abortion) or a simple outpatient procedure at a facility with required infrastructure.
- Unsafe when a pregnancy is terminated either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards or both. This includes abortions provided by untrained persons (backstreet providers/ quacks/ dai) and that involve ingestion of traditional concoctions, caustic substances or use of dangerous methods such as insertion of foreign bodies etc.
- Less safe when done through medical abortion drugs outside a health facility bought from a chemist with/without supervision. In India, it is estimated that about 73% of all abortions take place this way. It is important to note that the majority of these abortions result in successful outcomes and therefore WHO classifies these as “less safe”.
There is no evidence of an increase in unsafe abortions during the lockdown though some media reports share anecdotal stories. Women who undergo an unsafe abortion may face complications such as incomplete abortion (failure to remove or expel all of the pregnancy tissue from the uterus), haemorrhage (heavy bleeding), infection, uterine perforation (caused when the uterus is pierced by a sharp object) or damage to the genital tract and internal organs by inserting dangerous objects such as sticks, knitting needles, or broken glass into the vagina or anus. These could lead to morbidities or result in mortality. Psychological impacts range from anger, anxiety or depression--further compounded by economic burden.
Was access to contraceptives worse for women in rural areas?
Yes, it is worse for women in rural areas, due to:
- Social factors: stigma; traditional beliefs and norms that dismiss contraceptive use
- Logistical challenges: limited transport facilities; disrupted the supply chain and cross-border restrictions leading to stock-outs in chemist shops and/or health facilities
- Health-system related issues: reliance on community-level distribution by field health workers (mainly ASHA workers) that got impacted due to COVID-19.
With COVID-19 screenings made mandatory for procedures and an increase in demand for abortions, will costs go up? If yes, what can be done to prevent unfair practices from further keeping women away from accessing abortion services?
Given that in usual times, 73% of abortions happen outside the facility using medical abortion drugs, the increased need for facility-based abortions will significantly increase the cost of abortions for women, particularly for second-trimester abortions. This includes facility-level costs for additional lab tests, admission in the hospital (second-trimester abortion typically requires admission in contrast to first trimester ones that are day-care or OPD procedures) in addition to COVID-19-related hospital costs. There will be higher out-of-pocket expenditure including travel cost as well as opportunity cost as women may be required to travel longer distances than they did earlier to access abortion services.
To improve women’s access, it is important to conduct a rapid mapping of facilities (both public and private) to identify geographic distribution of those offering first or second-trimester abortion, followed by assessing facility preparedness and strengthening them to offer abortion services, especially second-trimester abortions. Capping of costs in private facilities as well as offering transport subsidies to women/families belonging to the poor socio-economic background are additional measures.
What should the government have done to ensure contraception/abortion access for women during the lockdown? What can be done if situations like these arise again?
We need to understand that the adverse outcomes from medical complications that resulted from lack of contraceptives and inadequate SRH services, including abortion, are very significant. It is hence crucial to plan and ensure that sexual and reproductive health should be embedded into the country’s disaster management plan. This includes ensuring sustained availability of essential SRH services during a crisis situation, as well as being an integral part of the relief measures.
- Comprehensive SRH services should continue during the crisis. For relevant consultations and follow-up, mobile clinics and telemedicine should be considered where feasible
- Streamlining supply chain and ensuring the availability of medical abortion drugs and contraceptives at all times
- Strengthening referral linkages, especially community-level linkages, to enable women seeking abortion services to access them
- Including mechanisms to offset additional travel and out-of-pocket expenditure
- Clear, consistent, and updated public health information should reach the community. We should reaffirm that medical complications outweigh the potential risk of transmission at health facilities and that women should continue to seek and receive care for all other essential SRH needs.
(Tiwari is a principal correspondent with IndiaSpend.)
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