Legal, but out of reach: Medical termination of pregnancy remains arduous for India’s young people

THE MEDICAL TERMINATION OF PREGNANCY (AMENDMENT) ACT, 2021, marked a significant step forward by the Government of India in expanding access to reproductive services and abortion care for all. This progressive legislation simplified the procedural requirements and extended the permissible gestation limits. Notably, the Act also extended the provision of Medical Termination of Pregnancy (MTP) services to unmarried people, thereby promoting inclusivity and ensuring reproductive rights for a broader segment of society. Despite the progressive changes introduced by the MTP Act, the accessibility of MTP services continue to be fraught with procedural rigmarole and attitudinal biases. This article seeks to present the hurdles faced by young women in accessing abortion services on the ground.Daisy*, a 19-year-old girl from a metropolitan city in India, lives with her mother and siblings. She got into an intimate relationship with an 18-year-old boy she met on a social media app and planned to get married to him. When his family refused to support their marriage, they eloped. They returned after his family assured them that they would not oppose their union. Upon returning, however, the boy's family broke their promise and arranged his engagement to another girl and the boy also started avoiding Daisy. .Despite the progressive changes introduced by the MTP Act, the accessibility of MTP services continue to be fraught with procedural rigmarole and attitudinal biases..After having missed her periods, Daisy discovered she was pregnant through a home pregnancy test. She informed the boy and he promised to marry her. But he blocked her from all communication and eventually Daisy confided in her mother and they filed an FIR under Section 69 of the Bharatiya Nyaya Sanhita (BNS) - "sexual intercourse by employing deceitful means". The boy was arrested and she was brought to the hospital for a medical examination by the police. Fearing further legal trouble, the boy’s family renewed their promise to get them married and care for the child. Trusting them, she decided to continue with the pregnancy and not seek MTP. She was eighteen weeks pregnant and returned home after the medical examination.A few more weeks passed by and Daisy realised that the boy’s family was merely trying to safeguard him and had no intentions of getting them married. At this stage, she was 22 weeks pregnant. Carrying the burden of the pregnancy alone, she discussed the repercussions with the mother and decided to go back to the hospital for an MTP. But upon her return, the gynaecology healthcare professionals reprimanded her for not seeking MTP when she first came for an examination. They asked her to bring a police memo if she wanted to terminate the pregnancy. The police stated that no such memo was required for a medical procedure but the health care professionals insisted on it. After a lot of back and forth, Daisy was able to get a memo from the police requesting for medical treatment and and was admitted..Supreme Court’s recent decisions on abortion pregnant with semantics, not necessarily justice.Despite being admitted for almost seven days, the MTP procedure was not initiated. The conversations amongst health professionals repeatedly shifted blame onto Daisy. They argued that it was consensual sex and that she should have thought about it before getting into the relationship. They even claimed that by filing a police complaint, she had, in fact, cheated the boy. There was no consideration to the psychological distress suffered by Daisy on account of an unwanted pregnancy as well as breach of promise to marry by her boyfriend. Daisy remained admitted at the hospital, believing that she would sooner or later receive the MTP service. On the eighth day of her hospital stay, health professionals informed her that she had crossed the 24-week mark and it was outside the scope of the hospital to provide her the service. Instead, they asked her to register for antenatal care services with the intention of carrying the pregnancy to term and put her in touch with a medical social worker. Daisy confided in the medical social worker that she did not want to continue the pregnancy and the social worker introduced her to a lawyer. They approached the court on her behalf, explaining her precarious condition. The Court heard the matter and referred her to the medical board. The medical board stated that the foetus had severe oligohydramnios and mega cisterna magna with very low possibility of survival. The board opined that going ahead with an unwanted pregnancy may also add to her mental stress. Based on the medical board’s opinion, the Court permitted Daisy to undergo MTP.What are the concerns that arise? Attitude of health care professionals: Despite all available provisions, the healthcare professionals’ judgements thwarted Daisy’s access to MTP. She had reached the hospital at 22 weeks of pregnancy. As per MTP Amendment Act, 2021, two registered medical practitioners could have evaluated her situation and offered her MTP. Instead, she was blamed for getting into a consensual relationship and the burden of child-bearing and child-rearing that would fall solely on her shoulders after being deserted by her partner was overlooked. .Healthcare professionals in India continue to be gatekeepers because of lack of awareness of their patients’ realities and social contexts..Inability to understand Daisy’s fragile emotional state: A woman who was cheated under promise of marriage was not even allowed to have a moment of fragility and emotional vulnerability, where she may momentarily rethink MTP under the hope that the boy may marry her. Instead, the narrative shifts to blaming her and expecting her to deal with the consequences. In Daisy’s case, her decision to not opt for MTP at the first instance was interpreted as her having the mental capacity to carry the pregnancy to term. This is a contravention to the landmark judgement of the Supreme Court from 2022 which acknowledges the dynamic context of women’s lived realities and suggests that registered medical practitioners (RMPs) should enable access to MTP services.Unlawful administrative procedures: Having arrived at a critical period of 22 weeks, Daisy required urgent attention. Yet unlawful procedures like the demand for a police memo or keeping her admitted without any indication about providing MTP, delayed her care. This was yet another violation of the Supreme Court’s judgement from 2022 which states that RMPs should steer clear of extra- legal conditions. In this case, the doctors demanded that Daisy bring a police memo to avail of MTP service. The medical board on the one hand recognised the mental stress of an unwanted pregnancy while on the other allowed MTP on the grounds of foetal anomalies leading to incompatibility with life. But one shudders to think of whether she would have been granted an MTP if such a medical condition of the foetus did not prevail. Conclusion This story is not just of Daisy’s but of hundreds of young women who are denied MTP services for an unwanted pregnancy. They are distressed, susceptible and often, not fully aware of what to expect from the health system. The Supreme Court, in its landmark decision in X vs. The Principal Secretary, Health and Family Welfare Department, Govt. of NCT of Delhi (2022)., noted that ‘the whole tenor of the MTP Act is to provide access to safe and legal medical abortions to women.’ But the ground reality is very different. Healthcare professionals in India continue to be gatekeepers because of lack of awareness of their patients’ realities and social contexts.Daisy's case underscores the urgent need for healthcare systems to provide comprehensive, empathetic and women-centred abortion services under the MTP Act. It also highlights the necessity for instilling gender-sensitive attitudes in healthcare professionals at the pre-service education so that they are exposed to reproductive rights perspectives and lived realities of the patients they treat. The least that Daisy, and each woman, deserves is dignity in access to healthcare..Notes: *Names changedThe authors thank Renu Khanna and Jagadeesh N Reddy for their review comments.

Legal, but out of reach: Medical termination of pregnancy remains arduous for India’s young people

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