How limited access to abortion changes Indian women's health and lives
This is the second story in a four-part series on abortion access in the country. (You can read the first part here.)
As Indian policies talk about comprehensive abortion services at primary health centres, many villages and small towns don’t have these facilities, leading people to resort to unsafe abortion services.
Azamgarh, Udaipur, New Delhi: As a girl growing up in small-town Uttar Pradesh, Pooja wanted to “get ahead in life.” She wanted to be a working woman, earn a comfortable living, and get out of the confines of her village. But her marriage soon after graduation — when she was just 21 — paused her plans.
Pooja, whose name has been changed to protect her privacy, lives in Azamgarh’s Atraulia block and has two sons, who are 7 and 12. “I was stuck taking care of two children,” she said. But she managed to study further and finished her bachelor's in education while her younger son was still a baby. Now, after working all day, she studies at night for government competitive exams for teacher jobs.
When she found that she was pregnant in December 2023, she was shocked. She always tracks her periods and uses condoms. This put a break on her career plans.
The Atraulia community health centre (CHC) and the Sau Saiya, a 100-bed government hospital, are the two closest public health facilities near Atraulia. There were no gynaecologists in the CHC, at the time we visited in May 2024. One Ayurvedic doctor was providing services to women in the hospital. Pooja, and many other women in this area, cannot afford the only legal private clinic for abortion, which reportedly charges about 15,000 rupees. At the time of writing, the CHC still doesn't have a gynaecologist, said Rajdev Chaturvedi, who runs a nonprofit called Gramin Punarnirman Sansthan, a rights-based feminist organization that works with women in the community and one of the few organizations in India that works on abortion rights.
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According to the Comprehensive Abortion Care guidelines published by the Ministry of Health and Family Welfare, women should get abortion care in primary health centres near their houses. But, as our reporting shows, this is not the case in many parts of the country.
This lack of access has been documented over the years, even by the National Health Mission. Every year, the Ministry of Health and Family Welfare organizes Common Review Mission (CRM) in several states across the country to undertake a rapid assessment of various health programs running under the National Health Mission. In what appears to be the last published Common Review Mission report from 2022, it was found that abortion services were lacking in several states. In Goa at the time, no abortion pills were available in government primary healthcare facilities and no one had availed of abortion services in the government for a year.
According to the National Family Health Survey 2019-21, about 3% of pregnancies end up in abortions. The number is higher in urban areas, and among dominant caste groups. Also, the share of abortions among pregnancies increases with the rise in wealth.
In some places, especially rural areas, not even a gynaecologist is available in primary health facilities, which result in people resorting to unsafe abortion services. Apart from Azamgarh, this correspondent went to some primary health centres of Pratapgarh and Udaipur districts in Rajasthan where abortion was not available, and women were referred to higher centres. Many women complained of being subject to indignities.
“There are no full-time gynaecologists in government hospitals at a 50 km radius distance,” Chaturvedi said. “Women who seek abortion are discreet, and do not want to travel all the way to Azamgarh city. It would seem suspicious in a village if they come back home late at night. They cannot risk becoming the scandal of the village. As a result they go to jholachaaps (quacks) risking their own lives.”
Unsafe abortion is the third leading cause of maternal mortality in the country. Close to eight women die from causes related to unsafe abortion every day, according to the State of World Population Report 2022 released by the United Nations Population Fund.
IndiaSpend sent a detailed questionnaire to Padmini Kashyap, deputy commissioner at the Ministry of Health and Family Welfare. We will update the story when we get a response.
Seeking abortion pills over the counter
Pooja did what most women in this area do for abortion. She took medical abortion pills from a chemist at a “medical hall,” a small area near the community health centre that has pharmacies, some qualified doctors, and some quacks. Three in four medication abortions done in India are outside of health facilities, according to a six-state study published in the Lancet in 2018.
As a result of the stigma of abortion and the unavailability of services, women resort to taking medical abortion pills on their own, with little or no supervision from registered healthcare providers. Data from the National Family Health Survey 2019-21 shows that two in three abortions are through this method, with a quarter of all women who have had abortions in the preceding 5 years saying the procedure was performed by “self.”
Abortion pills typically are a combination of drugs, mostly mifepristone followed by misoprostol. Under the Medical Termination of Pregnancy Act, only registered medical practitioners trained to provide abortion can prescribe these pills. These abortion pills are easily available over the counter in many parts of the country, and are the most common way of conducting an abortion.
Medical abortion pills are a “game-changer,” many doctors and people associated with access to abortion said. Before the early 2000s, septic abortions were common especially because of unsafe abortions. A septic abortion refers to infection that develops in and around the uterus during or after an abortion.
“Twenty years ago, every week I used to see four to five septic abortions, sometimes with intestines coming out of the uterine site,” said Seema Pandey, a well-known gynaecologist who runs Seema Hospital in Atraulia. “In the era of MTP kits (pills), we used to get some patients with excessive bleeding. But even those have reduced significantly now.” Unsafe abortions can result in the puncturing of organs around the uterus like intestines.
Pandey added: “I think more women are taking it before they are 2 months pregnant, which increases the success rate. The chemists are also now more knowledgeable. Whenever I prescribe an MTP kit, I write instructions on the paper, which is circulated.”
In Pooja’s case, her husband went to the chemist, who gave instructions that were passed down to her. She bled a little, but continued to be pregnant. She then went to an Ayurveda doctor (not allowed to conduct abortion under the MTP laws) who gave her more pills. “I had pills for more than a month, but continued to remain pregnant. The doctor then told me that she will have to do a procedure and it would cost me 5,000 [rupees]. I did not have that much money,” Pooja said.
Then, she went to the Sau Saiya near her house “to save money.” When she was getting an ultrasound there, the doctor told her that the “child has a heartbeat” and that she cannot get an abortion. She returned home, crushed.
Incomplete abortions
Though most self-managed abortions often work without event (one multinational study showed 89% success without medical intervention) the cases where bleeding doesn't stop could get tricky, and even dangerous.
Reena Mittal, a senior medical officer at Pannadhay Zanana Hospital located inside the RN Medical College, Udaipur, said that they treat women who have taken pills and bleed excessively or who have incomplete abortions. In her ward, she attends to about three to four such patients per day. Many of these patients are tribal women who come from areas as far as Neemuch in Madhya Pradesh, about 130 km from Udaipur.
Some of these are ectopic pregnancies — that is, a pregnancy inside the fallopian tube that cannot be terminated with the abortion pills and often needs surgical intervention. An ectopic pregnancy can rupture the fallopian tube, and can be fatal.
When 32-year-old Aradhana from Atraulia got pregnant in January 2024, she took abortion pills. Aradhana, whose name has been changed to protect her privacy, has two sons, ages 9 and 12. She had undergone two abortions before their birth due to problems in her pregnancies. She said that her later pregnancies with her boys were also complicated, requiring a lot of care and expensive medicines. She was actively avoiding pregnancies — she said that condoms were her preferred method of contraception.
But she realized she was pregnant last January, and took abortion pills soon after. She started bleeding immediately, as expected. But her bleeding wouldn't stop even after 15-20 days.
Medical abortion pills in India are approved up to 9 weeks of pregnancy. They have to be given in different doses depending on the length of the pregnancy. So for women who are taking MTP pills after 12 weeks, it may not work.
“I hear from these women that their husbands get the MTP pills from the chemist. Only after the woman has bled 15-20 days do they come to the hospital,” Mittal said. “I get women who come with hemoglobin of 1 gram/deciliter (normal hemoglobin count is 12 g/dl). I have seen them bleeding clots, which are more than 200g.” She added that these are medical emergencies and have to be handled immediately, and often require blood transfusion.
This can be particularly difficult for those who are poor and don't have basic living facilities to clean themselves.
Vinoj Manning, the CEO of IPAS Development, said that there's a stigma attached even to going to a hospital for excessive bleeding after taking MTP pills. IPAS is an international nonprofit that works toward improving abortion care and access to abortion.
“When women go to a facility after having MTP pills for continued bleeding, there is a lot of bias. Health providers often say, ‘Why are you coming to us after taking the pills,’ or imply that they deserve the pain. This makes it difficult for women undertaking self-care to go to a proper facility,” Manning said.
Denial of access
One major reason why facilities deny access is because abortion law is mixed up with the law against sex selection called Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994, or PCPNDT Act.
In the last Census done in 2011, the all-India child sex ratio at birth was 914 girls per 1,000 boys, a drop from 927 girls per 1,000 boys a decade ago, which has resulted in increased surveillance in some states. In a study published in 2015, researchers interviewed 19 service providers in western Maharashtra who said they had been denying abortions to avoid paperwork and dealing with “exploitation” by government health officers.
“While investigating the reasons behind the denial of abortion services, we understood that there was a conflation between the PCPNDT Act and MTP Act. This denial of services affects those from marginalized communities more than others,” said the coauthor of the study, Pritam Potdar. Potdar is the managing director of the nonprofit Samyak Communication and Research Centre, based in Pune, Maharashtra. Samyak advocates for gender equality and human rights.
When this correspondent asked Shiv Kumar Yadav, the Atraulia block program manager under the National Health Mission, about abortion services in the area, he said: “Abortion is illegal… sex selection is illegal. MTP ko zero maanke chalte hai (we do not or hardly perform MTP in this area).”
Potdar said that government employees have specific duties related to the PCPNDT Act. “Most will say they are not against abortion but that their duty is to stop sex determination. There is no clarity about the two laws,” Potdar said.
At the Sau Saiya hospital, the chief medical supervisor S.K. Dhruv said that “with the PCPNDT Act, we cannot support people who do sex determination. We do not take the risk of providing abortion.”
Potdar said that Samyak did qualitative research (unpublished) with 12 women from rural areas who were seeking abortion in 2015. Of them, eight continued pregnancy after being denied abortion services. Only one woman went to her aunt in Mumbai and spent more than 15,000 rupees for the abortion.
Quacks providing abortion
Aradhana is an educated woman and felt that she had to see someone about her bleeding soon. She then went to a woman who's well known in the area for providing abortion. But this woman is an ASHA sangini, or a trainer of accredited social health activists or ASHA workers, who runs a “clinic” with her husband. Both husband and wife have no medical degree or training for abortion.
“The ASHA sangini said I have to do a safaiya. I agreed,” Aradhana said. Safaiya — which translates as a cleaning out — basically refers to abortion evacuation procedure. The other words used colloquially are safai, dhulai, khali karvana, among others.
Aradhana said the ASHA sangini did a “procedure” and “prescribed” her some medicines. But the bleeding didn't stop. By then, Aradhana had bled out for a whole month. Then the ASHA sangini asked Aradhana to have a sonography done, for which Aradhana traveled another 30 km to a nearby town.
“She saw the report and told me there was a piece of fetus left in the uterus. I told her, ‘Listen, I have already borne so much pain. And shed so much blood for a month. And I am still stuck.’ She called me again, and did the procedure,” Aradhana said.
This time though, much to Aradhana’s surprise, the ASHA sangini insisted that her husband “doctor-saab” be present during the procedure. Despite Aradhana’s protestations that she didn't want him around, the ASHA sangini insisted on his presence. She said that he needed to watch the procedure and “guide” her.
“She just made me lie on the cot, injected me and did the procedure. This time the pain was so much more than the first time. I do not think I have borne such pain in my life. I was almost unconscious. She dropped me near my house in her car,” Aradhana said.
The humiliation of undergoing this procedure in front of this woman’s husband still rankled Aradhana. She spent about 8,000 to 10,000 rupees for this procedure, taking some temporary loans from her sister.
This correspondent met the ASHA sangini, who denied having seen or treated any person who needed abortion. She did have a board outside her house/clinic, with her husband’s name with the honorific "Dr." We also met a nurse who said that she conducted “dhulai” for women who needed it in 5 minutes.
“We need free abortion services at the public hospitals near us. I am too poor to afford this kind of treatment,” Aradhana said.
At around the same time, by February 2024, Pooja was about 2.5 months pregnant, still trying to get an abortion. After feeling defeated for a few days, she decided to borrow 5,000 rupees and get her abortion procedure done.
“I was so relieved and happy. I started studying that night itself,” Pooja said. She didn't clear the cut-off for a government teacher job by a few marks in December, and says she will continue trying.
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